Every finding on record at Arbor Care Centers - Ord, LLC

Licensure Reference Number 175 NAC 12-006.01(G)&(H) Based on record review and interview, the facility failed to notify the State Agency within 5 working days when there was a change in Administrator position. This had the potential to affect all facility residents. The facility census was 39. Findings are:A record review of the facility's undated Change of Administrator or Director of Nursing Notification Form revealed the facility had a change in administrator on 11/19/2025-11/20/2024. An interview on 9/24/2025 at 4:25 PM with the administrator and the facility owner (via telephone) confirmed the change in administrator form for the change that occurred on 11/19/2025-11/20/2024 was not sent to the State Agency until 12/16/2025. The owner confirmed this was outside of the required timeframe. A record review of the facility's undated Change of Administrator or Director of Nursing Notification Form revealed the facility had a change in administrator on 6/10/2025-6/11/2025. An interview on 9/24/2025 at 4:30 PM with the administrator and the facility owner (via telephone) confirmed the change in administrator form for the change that occurred on 6/10/2025-6/11/2025 was not sent to the State Agency until 7/12/2025. The owner confirmed this was outside of the required timeframe.

Licensure Reference Number 175 NAC 12-006.19Based on record review, interviews and observations, the facility failed to ensure cleanliness in the dining room; failed to ensure that room wall fans/ventilation were clean; and failed to ensure that the bath house was cleaned thoroughly to remove the buildup on the tub handles and the exhaust fans were free of dust. This had the potential to affect all facility residents. The facility census was 39. Findings are:A.Observation on 9/22/2025 at 9:55 AM in the 400-hallway bath house revealed the exhaust vent was covered with fuzzy, grey-colored particulates. The bathtub had a buildup on the knobs that was white in color, looked like soap scum or build-up of hard water deposits, and could be easily scraped off when scratched. Interview with Bath Aide (BA)-F on 9/22/2025 at 9:55 AM revealed that the bath house was cleaned between residents with the tub being sanitized for 10 to 15 minutes or more between residents. At the end of each day the entire bath house is to have a terminal (final thorough clean) daily by housekeeping. BA-F agreed that there were fuzzy particles on the exhaust fan in the 400 bath house. BA-F also agreed that there was a white build up on the plastic handles of the tub where the water is turned on and off. Interview with the Admin and Maint while touring the 400 hall bathhouse on 09/23/2025 at 9:45 AM confirmed that there was a white build up on the bathtub handles and the exhaust fan was not clean and had grey fuzzy particles on it. B.Observation in the dining room on 09/22/2025 at 12:25 PM revealed the windowsills were covered in a dusty and oily feeling build-up with dead bugs on the windowsill. Observation in the dining room on 09/23/2025 at 8:20 AM revealed the windowsills in the dining room continued to have a dusty, oily like residue on the windowsills and the dead bugs remained on the windowsills. Interview on 09/23/2025 at 9:27 AM with the Facility Administrator (Admin) who confirmed the windowsills in the dining area do have dusty residue and there are some dead bugs in the windowsills. C.Observation on 09/22/2025 at 10:30 AM of the ventilation fan covers in the hallway revealed there was a dusty and fuzzy build up in the hallway vent covers near the north and south outside emergency exits beside room [ROOM NUMBER]. Observation on 09/22/2025 at 10:40 AM of the room ventilation cover in room [ROOM NUMBER] revealed there was a fuzzy build up on the wall fans vent covers and the ventilation fan in the bathroom had a fuzzy dust build-up on the exhaust vent. Observation on 09/22/2025 at 12:10 PM of the room ventilation cover in room [ROOM NUMBER] revealed there was a fuzzy build up on the wall fans vent covers and the ventilation fan in the bathroom had a fuzzy dust build-up on the exhaust vent. Observation on 09/22/2025 at 12:12 PM of the room ventilation cover in room [ROOM NUMBER] revealed there was a fuzzy build up on the wall fans vent covers and the ventilation fan in the bathroom had a fuzzy dust build-up on the exhaust vent. Observation on 09/22/2025 at 12:15 PM of the room ventilation cover in room [ROOM NUMBER] revealed there was a fuzzy build up on the wall fans vent covers and the ventilation fan in the bathroom had a fuzzy dust build-up on the exhaust vent. Observation on 09/22/2025 at 12:30 PM of the room ventilation cover in room [ROOM NUMBER] revealed there was a fuzzy build up on the wall fans vent covers and the ventilation fan in the bathroom had a fuzzy dust build-up on the exhaust vent. Observation on 09/22/2025 at 12:40 PM of the room ventilation cover in room [ROOM NUMBER] revealed the ventilation fan in the bathroom had fuzzy dust like build up on the exhaust vent.

Licensure Reference Number 175 NAC 12-006.04(A)(iii)(3)Based on interview and record review, the facility failed to follow the facility policy and complete criminal background checks, and [NAME] (Sex Offender Registry) checks for 1 of 5 personnel files reviewed. This had the potential to affect all of the facility residents. The facility census was 39. Findings are: A record review of an active employee roster dated 09/12/2025 revealed Medication Aide (MA)-A had a current status of active. Record review of personnel files for MA-A revealed a date of hire of 10/28/2024. Further review of MA-A personnel file revealed no evidence of a criminal background check or [NAME] checks. An interview with the Administrator (Admin) on 9/23/2025 at 4:30 PM revealed the criminal background check and [NAME] check for MA-A had not been completed. An interview with the Admin on 9/24/2025 at 9:45 AM revealed corporate staff had not completed background check or [NAME] checks for MA-A prior to hire and/or working with facility residents. A review of the facility policy titled, Abuse-Neglect-and-Exploitation Policy dated September 2024 revealed a policy statement of It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. This included:Screening:-Potential employees will be screened for history of abuse, neglect, exploitation, or misappropriation of resident property.-Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students, students affiliated with academic institutions, volunteers, and consultants.-Screening may be conducted by the facility itself, third party agency or academic institution.-The facility will maintain documentation of proof that the screening occurred.

Licensure Reference Number 175 NAC12-006.04(H)(ii) Based on record review and interview, the facility failed to employ a Director of Food and Nutrition Services that met the regulatory educational requirements. This had the potential to affect all of the residents receiving meals from the kitchen. The facility census was 39. Findings are:A record review of a facility supplied document titled Department Heads revealed an employee name listed as the Dietary Manager (DM). A record review of facility supplied documents revealed no evidence of the DM having received the required education and no evidence of a qualified dietitian being employed full time. In an interview completed on 09/22/2025 at 10:15 AM with the DM, the DM confirmed they had not completed an educational program that met regulatory requirements. The DM also confirmed that the Registered Dietitian was not employed full time and completed facility visits and resident reviews on a monthly basis.

Licensure Reference Number 175 NAC 12-006.11(E) Based on record review, interviews, and observations; the facility failed to store and prepare food in safe and sanitary conditions. This had the potential to affect all residents receiving meals from the kitchen. The facility census was 39.Findings Are: A.Record review of an undated facility policy titled Food Safety Requirements revealed food safety practices shall be followed throughout the facility's entire food handling process. Food will be stored in a manner that helps prevent deterioration or contamination of the food. Record review of an undated facility policy titled Defrosting Freezers revealed freezers that are opened and closed frequently, or are located in humid environments, may need to be defrosted every 3 to 6 months. In an observation completed on 09/22/2025 at 10:00 AM an upright single door standard freezer was present in the facility dry food storage area. The interior of the freezer was observed to have a 3-4-inch layer of frost present to the inner top of the freezer. All items visible in the freezer were observed to have a thin opaque white layer of frost present covering their exposed packaging. In an interview completed on 09/22/2025 at 10:15 AM with the facility Dietary Manager (DM), the DM confirmed the layer of frost present on the single door standard freezer. The DM stated knowledge of it needing to be defrosted and cleaned stating had not been completed due to inability to store items while it was being defrosted. The DM confirmed that there should not be a buildup of frost on the interior of the freezer or the packaged items being stored in it and there was. B.Record review of an undated facility policy titled Food Safety Requirements revealed when preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce or eliminate potential hazards. Record review of a facility policy titled Hand Hygiene and dated September 2024 revealed all staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hand hygiene technique when using soap and water rub hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers. In an observation completed on 09/25/2025 at 9:25 AM of meal preparation [NAME] C placed a white piece of rectangle wax paper on the stainless-steel table they were using to prepare the afternoon meal. The cook used a white handled scoop to scoop out solid/frozen peach-colored cubes from a clear plastic bag. The cook placed these cubes in a clear plastic container to be weighed. The cook then placed the scoop that was used opening down on the piece of wax paper setting on the stainless-steel table. The cook then moved the scoop from one area of the wax paper to the other side. The cook removed their gloves and disposed of them in the trash. The cook returned to the stainless-steel table and placed their unwashed bare hand on the wax paper where the scoop had been lying. The cook then removed the clear plastic container from the scale and emptied the peach cubes into a rectangular baking pan. The cook then placed the pan into the convection oven. The cook then walked over to the sink and completed hand hygiene using soap and water for 10 seconds. In an interview completed on 09/25/2025 at 9:50 AM with [NAME] C, [NAME] C confirmed that the peach cubes were frozen raw chicken pieces. The cook confirmed that they did not complete hand hygiene after removing their gloves and placed their hand on the wax paper where the scoop had been placed potentially contaminating their hand with raw chicken and did not complete hand hygiene. The cook confirmed that hand hygiene with soap and water should include rubbing the hands with soap for at least 20 seconds. The cook confirmed that when they completed hand hygiene with soap and water they did not rug their hands for at least 20 seconds with soap. In an interview completed on 09/25/2025 at 9:55 AM with the DM, the DM confirmed that the cook should have washed their hands after removing their gloves and after touching the wax paper where the scoop used on frozen raw chicken had been placed and did not. The DM confirmed when [NAME] C did complete hand hygiene with soap and water they did not rub their hands with soap for at least 20 seconds.

Licensure Reference Number 175 NAC 12-007.04(D) Based on observation and interview, the facility failed to ensure that that exhaust fans in the resident rooms on the 400 hallway were in working order. This affected 12 (Residents 3, 5, 10, 14, 17, 18, 19, 30, 31, 39, 40, and 45) of 12 sampled residents. The facility census was 39. Findings are: A.Observation on 09/22/2025 at 10:15 AM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. B.Observation on 09/22/2025 at 10:35 AM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. C.Observation on 09/22/2025 at 10:40 AM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. D.Observation on 09/22/2025 at 12:10 PM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. E.Observation on 09/22/2025 at 12:12 PM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. F.Observation on 09/22/2025 at 12:15 PM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. G.Observation on 09/22/2025 at 12:30 PM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. H.Observation on 09/22/2025 at 12:40 PM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. I.Observation on 09/22/2025 at 1:10 PM AM in resident room [ROOM NUMBER] revealed that the bathroom exhaust vent would not pull up a 1-ply square of toilet paper. Interview on 09/23/2025 at 9:25 AM with the Maintenance Supervisor (Maint) who revealed they were not aware that the vents in these rooms were not working as required. Interview on 09/23/2025 at 9:27 AM with the Facility Administrator who confirmed not knowing the ventilation fans were not working in the 400 hallway.

Licensure Reference Number 175 NAC 12-006.05(B) Based on interview and record review, the facility staff failed to provide documentation that a written notice of Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, a notice issued to a resident and/or their responsible party to inform them that Medicare will likely no longer pay for their services) for 3 (Residents 25, 28, and 46) of 3 sampled residents when their Medicare A services ended. The facility census was 39. Findings are: A record review of Centers for Medicare and Medicaid Services (CMS) Guidelines with the Admin on notification of non-coverage (NOMNC, SNF ABN, ABN, DENC) undated revealed the following: Purpose: to comply with CMS regulations on proper notification of coverage termination to Medicare beneficiary and to release facility from financial responsibility. Standard: Timely and proper completion of CMS forms by facility as it related to CMS guidelines. Advance Beneficiary Notice provides written notice to beneficiary that therapy services may not be covered by Medicare. Allows the beneficiary to make an informed decision about whether to get the item or service that is not covered and accept financial responsibility if Medicare does not pay. Should be provided to Beneficiary when an item or service is not considered reasonable and necessary under Medicare Program Standards. A record review of the Entrance Conference Worksheet Beneficiary Notice-Residents discharged in the Last 6 Months received from the Administrator (Admin) revealed Resident 25, Resident 28, and Resident 46 were listed as having been discharged from Medicare A services with Medicare A days remaining. A.A record review of the SNF Beneficiary Notification Review for Resident 25 revealed the Medicare Part A Skilled Services Episode Start Date was 02/28/2025 and the last covered day of Part A Service was 3/31/2025. The Medicare Part A Service Termination/Discharge determined was listed as: the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The SNF ABN was not provided with the reason being listed as Resident had Med A days left, facility error. Resident 25 remained in the facility after their Medicare A services ended. B.A record review of the SNF Beneficiary Notification Review for Resident 28 revealed the Medicare Part A Skilled Services Episode Start Date was 06/03/2025 and the last covered day of Part A Service was 07/25/2025. The Medicare Part A Service Termination/Discharge determined was listed as: the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The SNF ABN was not provided with the reason being listed as Resident had Med A days left, facility error. Resident 28 discharged from the facility to home when Medicare A services ended. C.A record review of the SNF Beneficiary Notification Review for Resident 46 revealed the Medicare Part A Skilled Services Episode Start Date was 05/07/2025 and the Last covered day of Part A Service was 06/20/2025. The Medicare Part A Service Termination/Discharge determined was listed as: the Resident initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The SNF ABN was not provided with the reason being listed as Resident had Med A days left, facility error. Resident 46 discharged from the facility to home after their Medicare A services ended. Interview with the Administrator (Admin) on 09/23/2025 at 10:40 AM revealed this was a facility error in not providing this information to the resident when revealed they had not issued the SNF ABN to Residents 25, 28, and 46.

Licensure Reference Number175 NAC 12-006.10(D) Based on record review, interviews, and observations, the facility failed to ensure that there were no significant medication errors. This affected one (Resident 17) of 7 sampled residents. The facility census was 39.Findings are: Record review of the Medical Diagnoses for Resident 17 revealed Resident 17 had a diagnosis of multiple myeloma (a type of cancer that develops in the plasma cells, which are white blood cells that produce antibodies to fight infections), not yet in remission. Record review of Resident 17's Physician Telemed visit with their oncologist (physician who specializes in cancers and blood disorders) dated 08/16/2024 revealed Resident 17 started lenalidomide (a specialized medication used to treat multiple myeloma)for multiple myeloma during the month of 07/2023. This medication was ordered to be given on a 28-day cycle where Resident 17 received lenalidomide 10 mg capsule oral daily for 21 days and then had 7 days with no medication before starting another 28-day cycle. Record review of the Medication Administration Record (MAR) revealed that the medication was ordered to be given on a 28 day cycle with Resident 17 receiving 21 days of the medication and then having 7 days off before beginning a new cycle. The order stated: Revlimid Oral Capsule 10 MG (lenalidomide) give 1 capsule orally one time a day related to Multiple Myeloma not having achieved remission (C90.00) for 21 days. The order had a start date of 09/12/2024 and no end date. Resident 17 started a 28 day cycle on Thursday, 09/12/2024. A record review of the October 2024 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days and off 7 days ended on Wednesday, 10/02/2024. There was to be a 7-day break with no medication and then medication was ordered to restart on Thursday, 10/09/2024. The October MAR revealed this medication did not restart until Tuesday, 10/22/2024, 13 days past the date that the medication should have started, and continued through the end of the month. A record review of the November 2024 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days and off 7 days was on the MAR and the medication administration ended on Monday, 11/11/2024. This was to be followed by 7 days with no medication administration and then restarted on Monday, November 18, 2024. The lenalidomide was not restarted in the month of November 2024. A record review of Resident 17's Physician Orders revealed no evidence of an order to stop the administration of the lenalidomide. A record review of the December 2024 MAR revealed that Resident 17 did not receive any of the lenalidomide during this period. A record review of the January 2025 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR and the medication administration started on Thursday, 01/03/2025 and ended on Wednesday, 01/23/2025. The medication should have been restarted on 01/30/2025, but the medication was not restarted in the month of January. A record review of the February 2025 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR and the medication administration started on Saturday, 02/01/2025, and should have been started on 01/30/2025. Record review of a medication error report dated 04/14/2025, was sent to Resident 17's primary care physician and revealed that there was an order for the medication lenalidomide that was to be given in 28-day cycles for Resident 17's multiple myeloma, not in remission. The errors started in the month of October 2024 and continued throughout the month of December 2024. This significant medication error stated: Concerning Revlimid take 21 days of (off) 7 days regimen. Medication should have started the 10th of October for a 21 day cycle supply but was started on the 22nd of October and completed on 11/11/2024. Revlimid 10 mg should have been restarted on 11/19/2024 and went through until 12/9 off until 12/16 restarted on 12/17 given for 21 days which would have been until 12/28 stop 12/29 and restarted on 1/4/2025. Was restarted on 1/3/2025 off 1/22 and restarted on 1/30/25 but was restarted 2/1/25. Has been on track regimen since 2/1/25. Staff has been educated and medication regimen in computer until [DATE] finishing on 10/10 with an alert if medication is continued to input order after 10/10/2025. A record review of Resident 17's medical records revealed no evidence of the resident's oncologist being notified of the medication errors. A record review of Resident 17's April 2025 MAR revealed the order for lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR. The 21 day cycle started on March 30, 2025 and stopped on April 19, 2025.The medication was not given on 04/15, 04/16, or 04/17. The nurses noted revealed the medication was unavailable. Interview on 09/23/2025 at 10:30 AM with Infection Control and Preventionist (IP) revealed that Resident 17 took this medication for 21 days, then had a rest period for 7 days, then the cycle started again. The medication and rest cycle was a 28-day cycle. There was no order to stop the medication at any point. IP confirmed the facility made a mistake by not getting the lenalidomide back on the MAR as the facility could only put about 3 or 4 months into the medication order system to show up on the MAR and then fell off. The facility would then have to manually input that order back into the system. IP stated this medication only came from one source and the facility had to call to have it delivered for each cycle. IP stated the facility could not order it in advance, as in 2 or 3 months at a time, the facility had to order it as each cycle ended and the next cycle was about to begin. IP confirmed the facility had an issue realizing that the medication had slipped off of the MAR and that there were several doses that were missed during the months of November and December 2024. Interview on 09/23/2025 at 2:45 PM with IP confirmed that there had been many doses not given and significant medication errors were made with the medication administration of lenalidomide for Resident 17.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on record review, observation, and interview, the facility failed to ensure that reusable respiratory equipment was labeled, cleaned, and stored per facility policy after use to prevent the potential for infection. This affected one (Resident 5) of one resident sampled. The facility census was 39. Findings are: Record review of the facility policy Infection Prevention and Control Program dated February 2025 stated this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted [NAME] standards and guidelines. On page 3 of 5, subsection Equipment Protocol, the policy stated: All reusable items and equipment requiring special cleaning, disinfection or sterilization shall be cleaned in accordance with out current procedures governing the cleaning and sterilization or soiled or contaminated equipment. Reusable items potentially contaminated with infections materials shall be placed in an impervious clear plastic bag. Observation in the room of Resident 5 on 9/22/2025 at 10:00 AM revealed a nebulizer (A device used to deliver aerosolized respiratory medications) that had been used for a medication treatment sitting on top of the nebulizer machine. The nebulizer was not labeled, had been used and was not clean, and was not in a plastic bag. Interview with the Infection Control Preventionist (IP) on 09/23/2025 at 2:45 PM confirmed that nebulizers and all oxygen equipment and tubing were to be labeled and dated, cleaned after use, and then stored per the facility policy. Interview on 09/23/2025 at 7:53 PM with the Facility Administrator (Admin) confirmed the nebulizer should have labeled, cleaned, then put into a plastic bag after use.

Licensure Reference Number 175 NAC 12-006.10(D) Based on record review, observation, and interview; the facility failed to ensure the medication administration error rate was 5% or less. Of the 25 medication administration opportunities, there were 13 errors and the error rate was 52%. This affected 2 (Residents 31 and 16) of 4 sampled residents. The facility census was 39.Findings are: Record review of the facility policy Medication Administration dated September 2024 revealed that within the policy explanation and compliance guidelines the following:Ensure the six rights of medication administration are followed:-Right resident-Right drug-Right dosage-Right route-Right time-Right documentationReview the Medication Administration Record (MAR) to identify medication to be administered. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. A.Record review of the September 2025 Medication Administration Record (MAR) for Resident 31 revealed that medications were due for administration at 8:00 AM. The medications due at 8:00 AM were aspirin 31 milligrams (mg), Qulipta (a medication to prevent migraines) 60 mg, baclofen (a muscle relaxant and antispasmodic) 10 mg, Vitamin B-12 250 micrograms (MCG), ferrous sulfate 325 mg, fluoxetine (an antidepressant) 30 mg, gabapentin (an anticonvulsant medication) 100 mg, lamotrigine (a medication for epilepsy) 100 mg, pantoprazole (decreases stomach acid) 40 mg, Xarelto (prevents blood clots) 10 mg, senna docusate (for constipation) 8.6-50 mg oral 2 tablets, and Vitamin D3 1000 unit capsules 2 capsules. Observation on 09/24/2025 beginning at 9:27 AM of Licensed Practical Nurse (LPN)- T who prepared and administered medications the above listed medications to Resident 31. Interview on 9/24/2025 at 9:48 AM with LPN-T confirmed that the medications given to Resident 31 at 9:43 AM were all administered late and at the wrong time. B.Record review of the September 2025 MAR for Resident 16 revealed a medication order for Voltaren cream 4 grams to be administered twice a day topically and twice a day as needed 4 grams topically. Observation on 09/25/2025 at 8:15 AM of Medication Aide (MA) B who took the tube of Voltaren cream, squirted approximately a quarter sized dollop of the medication into MA-B's gloved hand, then applied the medication to the back of the neck of Resident 16. After rubbing the medication onto Resident 16, MA-B removed both gloves, performed hand hygiene, and then charted the medication. Interview on 09/25/2025 at 8:20 AM with MA-B who stated it was the experience of MA-B that about a quarter-sized dollop of the medication was approximately 4 grams. MA-B stated the medication did come with a medication measuring card but MA-B did not know where that card was located. MA-B confirmed the order for Resident 16 did read that there was to be 4 grams applied and without the use of the medication card to measure the medication it was unknown if the resident had received 4 grams. MA-B confirmed this was a medication error due to the wrong dose being administered.

Licensure Reference Number 175 NAC 12-006.12 Based on record review, observations, and interviews; the facility failed to ensure medications were ordered, available, and administered as ordered by a physician for 1 (Resident 17) of 1 sampled resident. The facility census was 39. Findings are: Record review of the Medical Diagnoses for Resident 17 revealed Resident 17 had a diagnosis of multiple myeloma (a type of cancer that develops in the plasma cells, which are white blood cells that produce antibodies to fight infections), not yet in remission. Record review of Resident 17's Physician Telemed visit with their oncologist (physician who specializes in cancers and blood disorders) dated 08/16/2024 revealed Resident 17 started lenalidomide (a specialized medication used to treat multiple myeloma) for multiple myeloma during the month of 07/2023. This medication was ordered to be given on a 28-day cycle where Resident 17 received lenalidomide 10 mg capsule oral daily for 21 days and then had 7 days with no medication before starting another 28-day cycle. Record review of the September 2024 Medication Administration Record (MAR) revealed that the medication was ordered to be given on a 28 day cycle with Resident 17 receiving 21 days of the medication and then having 7 days off before beginning a new cycle. The order stated: Revlimid Oral Capsule 10 MG (lenalidomide) give 1 capsule orally one time a day related to Multiple Myeloma not having achieved remission (C90.00) for 21 days. The order had a start date of 09/12/2024 and no end date. Resident 17 started a 28 day cycle on Thursday, 09/12/2024. A record review of the October 2024 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days and off 7 days ended on Wednesday, 10/02/2024. There was to be a 7-day break with no medication and then medication was ordered to restart on Thursday, 10/09/2024. The October MAR revealed this medication did not restart until Tuesday, 10/22/2024, 13 days past the date that the medication should have started and continued through the end of the month. A record review of the November 2024 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days and off 7 days was on the MAR and the medication administration ended on Monday, 11/11/2024. This was to be followed by 7 days with no medication administration and then restarted on Monday, November 18, 2024. The lenalidomide was not restarted in the month of November 2024. A record review of Resident 17's Physician Orders revealed no evidence of an order to stop the administration of the lenalidomide. A record review of the December 2024 MAR revealed that Resident 17 did not receive any of the lenalidomide during this period. A record review of the January 2025 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR and the medication administration started on Thursday, 01/03/2025 and ended on Wednesday, 01/23/2025. The medication should have been restarted on 01/30/2025, but the medication was not restarted in the month of January. A record review of the February 2025 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR and the medication administration started on Saturday, 02/01/2025, and should have been started on 01/30/2025. A record review of the March 2025 MAR revealed that Resident 17's order for the medication administration of lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR and the medication administration started on Saturday, 03/01/2025. The medication was stopped on Friday, 03/21/2025. The next 28-day cycle started on Sunday, 03/30/2025. A record review of Resident 17's April 2025 MAR revealed the order for lenalidomide 10 mg daily for 21 days with 7 days off was on the MAR. The 21 day cycle started on March 30, 2025 and stopped on April 19, 2025.The medication was not given on 04/15, 04/16, or 04/17. The nurses noted revealed the medication was unavailable. Record review of a medication error report dated 04/14/2025, was sent to Resident 17's primary care physician and revealed that there was an order for the medication lenalidomide that was to be given in 28-day cycles for Resident 17's multiple myeloma, not in remission. The errors started in the month of October 2024 and continued throughout the month of December 2024. This significant medication error stated: Concerning Revlimid take 21 days of (off) 7 days regimen. Medication should have started the 10th of October for a 21 day cycle supply but was started on the 22nd of October and completed on 11/11/2024. Revlimid 10 mg should have been restarted on 11/19/2024 and went through until 12/9 off until 12/16 restarted on 12/17 given for 21 days which would have been until 12/28 stop 12/29 and restarted on 1/4/2025. Was restarted on 1/3/2025 off 1/22 and restarted on 1/30/25 but was restarted 2/1/25. Has been on track regimen since 2/1/25. Staff has been educated and medication regimen in computer until [DATE] finishing on 10/10 with an alert if medication is continued to input order after 10/10/2025. A record review of Resident 17's medical records revealed no evidence of the resident's oncologist being notified of the medication errors. Interview on 09/23/2025 at 10:30 AM with Infection Control and Preventionist (IP) revealed that Resident 17 took this medication for 21 days, then had a rest period for 7 days, then the cycle started again. The medication and rest cycle was a 28-day cycle. There was no order to stop the medication at any point. IP confirmed the facility made a mistake by not getting the lenalidomide back on the MAR as the facility could only put about 3 or 4 months into the medication order system to show up on the MAR and then fell off. The facility would then have to manually input that order back into the system. IP stated this medication only came from one source, a specialty pharmacy, and the facility had to call to have it delivered for each cycle. IP stated the facility could not order it in advance, as in 2 or 3 months at a time, the facility had to order it as each cycle ended and the next cycle was about to begin. IP confirmed Resident 17 missed a couple of 28-day cycles. Interview on 09/23/2025 at 4:40 PM with the IP confirmed that the medication is ordered from only one pharmacy, a specialty pharmacy, and that 21 pills at a time are delivered prior to each 28-day cycle. IP receives an email from the specialty pharmacy that states it is time to reorder the medication. However the IP does not keep these emails after the medication is delivered. These medications can only be ordered one cycle at a time and must be ordered just before starting a cycle. Interview on 09/23/2025 at 5:15 PM with a representative of the specialty pharmacy in the office of the IP with the IP in the room. This interview was conducted with the phone on speaker. The pharmacy representative stated medications had been ordered and delivered on the following dates, 21 pills at a time, each order was enough to complete one 28-day cycle (Also included are the dates when medications were documented but there were no deliveries from the pharmacy.);-08/29/2024 delivered (for the cycle administered 09/12/2024 to 10/10/2024-No medication delivered during the month of September 2024-No medication delivered for the cycle documented as administered from 10/22/2024 to 11/11/2024-No medication delivered during the month of October 2024-No medication delivered during the month of November 2024-12/24/2024 delivered (for the cycle administered 01/03/2025 to 01/23/2025)-01/16/2025 delivered (for the cycle administered 02/01/2025 to 02/21/2025)-No medication delivered during the month of February 2025.-No medication delivered during the month of March 2025-No medication delivered for the cycle documented as administered from 03/01/2025 to 03/21/2025-No medication delivered for the cycle documented as administered from 03/30/2025 to 04/19/2025-04/20/2025 delivered (for the cycle administered 04/27/2025 to 05/17/2025)-05/15/2025 delivered (for the cycle administered 05/26/2025 to 06/15/2025)-06/06/2025 delivered (for the cycle administered 06/24/2025 to 07/14/2025)-07/15/2025 delivered (for the cycle administered 07/23/2025 to 08/12/2025)-08/142025 delivered (for the cycle administered 08/21/2025 to 09/10/2025)-09/17/2025 delivered (for the cycle administered 09/19/2025 to be completed on 10/10/2025)The pharmacy representative confirmed that no medications had been ordered or sent to the facility during the months of September 2024, October 2024, November 2024, February 2025, or March 2025. Interview with on 09/23/2025 which started at 4:40 PM with the IP continued following the phone call with the pharmacy representative. The IP could not state when or where the medications for the medications were obtained for the months the pharmacy representative stated there were no deliveries. The IP was unable to show medication receipts to show that these medications were ordered or received. Interview on 9/25/2025 at 11:10 AM with Registered Nurse (RN) H stated knowing there were times when there was no medication available for Resident 17. Interview with RN-H on 9/25/2025 at 4:45 PM confirmed that the medication only comes one bottle at a time and that there are only 21 pills that are sent for each cycle. RN-H had never seen any extra medication in the medication cart at any time. Interview on 9/25/2025 at 5:15 PM with Medication Aide (MA) B who stated a couple of months ago, unsure of the dates but only that it was a couple of months ago, there was an extra bottle of medication in the medication cart. That extra medication was kept in a baggy in the back of the top drawer of the medication cart for Resident 17. There was a second bottle that was at that time being used and was only about 1/2 full we were in the middle of a 28-day cycle of the lenalidomide.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(2) Based on interview and record review the facility failed to provide activities in accordance with the residents expressed interests for 1 (Resident 1) of 2 sampled residents. The facility census was 39. Findings are:A record review of a facility policy titled Activities and not dated revealed it is the policy of the facility to provide and ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. A record review of an admission Record revealed the facility admitted Resident 1 on 02/21/2025 with diagnoses of Type 2 Diabetes Mellitus (a condition where the body does not produce enough insulin for the body to utilize sugar in the blood stream), hypertension (High blood pressure), and generalized muscle weakness. A record review of Resident 1's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 08/28/2025 revealed Resident 1 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15/15, indicating the resident was cognitively intact. The resident utilized a wheelchair for mobility and was dependent on staff assistance propelling the wheelchair throughout the facility. A record review of Resident 1 Care Plan revealed a focus of personalized care with an intervention listed of participating in religious services to be very important to the resident. In an interview completed on 09/22/2025 at 1:45 PM with Resident 1, Resident 1 stated that they wished the facility offered religious services other than Catholic Mass. The resident stated they really missed going to church and would enjoy attending church services. Record review of the facility supplied activities calendar for the month of July 2025 revealed Catholic Communion being offered every Sunday. No other religious services or activity offerings were listed on the calendar for the month. Record review of the facility supplied activities calendar for the month of August 2025 revealed Catholic Mass being offered every Sunday and Bible Study to be offered every Tuesday. No other religious services or activity offerings were listed on the calendar for the month. Record review of the facility supplied activities calendar for the month of September 2025 revealed Catholic Communion being offered every Sunday and Bible Study was offered on the last Tuesday of the month. No other religious services or activity offerings were listed on the calendar for the month. In an interview completed on 09/25/2025 at 1:45 PM with the facility Administrator (Admin), confirmed the only religious services offered in the facility for the last 3 months was Catholic Mass or Communion and Bible Study.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview the facility failed to report incidents and/or accidents as required to the regulatory agency for 1 resident (Resident 38) of 2 sampled residents. The facility census was 39. Findings are:A record review of a facility policy titled Incidents and Accidents revealed the purpose of incident reporting includes meting regulatory requirements for the reporting of incidents and accidents. A record review of a facility policy titled Abuse revealed the facility will report all alleged violations to the state agency, adult protective services and to all other required agencies with in specified time frames. A record review of an admission Record revealed the facility admitted Resident 38 on 12/12/2022 with a diagnosis of quadriplegia, which is a form of paralysis that affects all for limbs and the torso often resulting from a spinal cord injury in the neck region. A record review of Resident 38's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 07/10/2025 revealed Resident 38 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15/15, indicating the resident was cognitively intact. The resident was dependent on staff assistance with bed mobility, transfers, and toilet use. A record review of Resident 38's Progress Notes for the month of September 2025 revealed documentation that on 09/17/2025 the resident was observed to have a red raised area to the dorsal surface of their right hand. The resident informed staff they had fallen asleep with their blow dryer on and the blow dryer caused the burn on their hand. Record review of a facility supplied document titled Incidents and Accidents revealed documentation of a incident report being completed on 09/17/2025 consistent with the documentation present in the progress notes. In an interview completed on 09/25/2025 at 11:00 AM with the facility Administrator (Admin), the Admin confirmed that Resident 38 had a self inflected burn to their right hand on 09/17/2025. The Admin confirmed that this incident was not reported to the necessary regulatory agencies as outlined in the facility abuse policy. The Admin confirmed that this incident should have been reported per the facility policy and was not.

Licensure Reference Number: 175 NAC 12-006.11(E) Based on observations, record review, and interviews; the facility failed to store food under sanitary conditions as evidenced by rodent droppings in and around the food storage areas. This had the potential to affect all facility residents. Facility census was 32. Findings are: Source: Nebraska Food Code, effective date 07/21/2016 revealed section: 3-305.11: Food Storage: A. Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: -In a clean, dry location; -Where it is not exposed to splash, dust, or other contamination; and -At least 15 cm (6 inches) above the floor. A review of the facility policy titled; Dietary Sanitation Policy Statement revealed: All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. Observation on 08/19/2024 at 8:35 AM revelaed the Food Services Supervisor (FSS) directed surveyor towards the back of the facility where a kitchen was presented with a dry storage on the east of the kitchen, dishwashing machine, stoves, and ovens. The dry storage had items labeled, and stored off of the floor. Underneath the dry storage was a 4-inch gap between the shelving and the floor, where visible were individual food packs of cookies, condiments and 4 wooden snap mouse traps. The FSS then lead the surveyor towards the main storage area that contained a refrigerator, 5 stand alone freezers and 2 large dry food storage wire shelving units that held dry food items, and another large shelving unit that held canned food items. The floors of the area were observed to have dried pasta, corn kernels and a buildup of dark soiling. Also observed were mouse droppings littered all over the floor with a concentration of droppings in specified areas of the storage room. There is a two-door entryway for deliveries where sticky mouse traps were present by the door and a cluster of mouse droppings. On 08/19/2024 at 2:12 PM Cook-I is observed to be retrieving food items from the food storage area of dry goods and refrigerated items. The items are placed on a rolling cart and brought to the kitchen where food is prepared. After the food is prepared, the food is kept hot in the oven. Once food is ready to be served, the food is then moved to the serving kitchen/dining room, where the food is then placed into a steam table and served to the residents. The FSS was interviewed on 08/19/2024 at 2:26 PM. The FSS revealed they were aware of the mouse droppings and stated they did not have the live mouse traps available to the kitchen. The FSS also revealed more cleaning needs to be done.

Licensure Reference Number: 175 NAC 1-009.01(C) Based on observations, record review and interviews, the facility failed to maintain an effective pest control program as evidenced by rodent droppings in and around the food storage areas. This had the potential to affect all facility residents. Facility census was 32. Findings are: A review of an undated facility policy titled Pest Control, indicates the facility shall maintain an effective pest control program. The policy further implements that the facility will maintain an on-going pest control program to ensure that the building is kept free of insects and rodents. Observation on 08/19/2024 at 8:35 AM the Food Services Supervisor (FSS) directed the surveyor towards the back of the facility towards a kitchen with a dry storage on the east side of the kitchen. Under the dry storage was a 4-inch gap, that had food items and 4 wooden snap mouse traps. The FSS then lead the suerveyor towards the main storage area that contained a refrigerator, 5 stand alone freezers, 2 large dry food storage wire shelving units that held dry food items, and another large shelving unit that held canned food items. The floors of the area were observed to have dried pasta, corn kernels and a buildup of dark soiling present. Also observed were mouse droppings littered all over the floor with a concentration of droppings in specified areas of the storage room. There is a two-door entryway for deliveries where sticky mouse traps caught with dead bugs were present by the doors and a cluster of additional mouse droppings. The FSS was interviewed on 08/19/2024 at 2:26 PM. The FSS revealed they were aware of the mouse droppings and stated they did not have the live mouse traps available to the kitchen as they typically did in other areas of the facility. The FSS stated they cleaned it up, however more cleaning needs to be done. An interview with the Facility Administrator (FA) on 08/19/2024 at 5:05 PM revealed they were unaware of the rodent droppings in the dry food storage area.

Licensure Reference Number 175NAC 12-007.04(D) Based on observation, and interview; the facility failed to ensure the bathroom ventilation system could pull up a square of single ply tissue in 3 rooms, (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]), of 16 sampled rooms. The facility census was 33. Findings are: In an observation completed on 08/22/2024 at 9:30 AM it was observed that the vent located in the ceiling of the bathroom of room [ROOM NUMBER] could not pull up a single ply of tissue. In an observation completed on 08/22/2024 at 9:31 AM it was observed that the vent located in the ceiling of the bathroom of room [ROOM NUMBER] could not pull up a single ply of tissue. In an observation completed on 08/22/2024 at 9:32 AM it was observed that the vent located in the ceiling of the bathroom of room [ROOM NUMBER] could not pull up a single ply of tissue. In an interview completed on 08/22/2024 at 9:56 AM with the Maintenance Manager (MM), confirmed that the vents located in the ceilings of the bathrooms in room [ROOM NUMBER], 307, and 311 could not pull up a single ply of tissue. The MM confirmed that the vents should be able to pull up a single ply of tissue and that the ventilation system was not working properly.

Licensure Reference Number 175NAC ,d+[DATE].19 Based on observation and interviews; the facility failed to maintain flooring that was stain free, ceiling tiles that are stain free, lighting fixtures that are bug and/or pest free, and thresholds that are free of trip hazards for 4 (Halls 300, 400, 500, and 700) of 5 sampled hallways. The facility census was 33. Findings are: In an observation completed on [DATE] from 7:25 PM to 8:20 PM the following was observed: A. In the 300 Hall in front of the door labeled Dining the carpet in front of the door is black and shiny in color from the threshold of the doorway extending 5 to 6 inches into the hallway where it fades to a gray color and then into the brown cream coloring of the carpeting squares. In the 300 Hall the carpeting between room [ROOM NUMBER] and 311 a large dark colored ring extending from the wall to the middle of the hallway. In the commons area in front of the nurse's station gray black circular discolored areas. B. In the 400 Hall on the exit side of the fire doors the ceiling tiles stained black, red fading into brown circles with the stained discolored area protruding down from the flat surface of the other ceiling tiles. The area is 3 ceiling tiles long and 2 ceiling tiles wide. In the 400 Hall first light fixture in the ceiling entering the hall is a black multi legged deceased bug approximately the size of a quarter. In the 400 Hall in front of room [ROOM NUMBER] a large dark gray black colored circular area extending from the threshold of the entry to the room approximately 4 inches into the hallway. In the 400 Hall the thresholds of Rooms 400, 402, 403, 406, 408, and 409 the carpet is loose, and the laminate flooring is loose from the underlayment beneath creating a trip hazard for residents. C. In the 500 Hall on the exit side of the fire doors the ceiling tiles are stained orange fading into a red brown color. The area is 2 ceiling tiles long and 4 ceiling tiles wide. In front of room [ROOM NUMBER] the ceiling tiles are yellow brown in color extending from the entrance to the room across 3 sections of ceiling tile. D. In the 700 Hall rooms [ROOM NUMBERS] the flooring of the threshold is carpet going to tile. The carpet is loose in the inner corner coming up from being secured to the floor. The tile is chipped and cracked exposing the sub floor underneath creating an uneven area where black, thick brown substance has collected and built up. In an interview on [DATE] at 9:56 AM with the Maintenance Manager (MM) the MM confirmed that the ceiling tiles were warped and stained and needed replaced. The MM stated that a water leak had been repaired but the ceiling tiles had not been replaced yet. The MM stated that the carpets are cleaned twice a year by an outside company and the facility does not perform any carpet cleaning in between these cleanings. The MM confirmed that the carpet throughout the facility had different degrees of staining present and needed cleaned more frequently. The MM confirmed the bug present in the 400-hall light fixture and that the carpeting and tile were cracked and coming loose on the thresholds of some of the doorways of the resident rooms.

Licensure Reference Number 175NAC 1-005.06(E) Licensure Reference Number 175NAC 12-006.18(B) Based on record review and interview the facility failed to complete and review pre-employment health histories for 4 of 4 sampled staff. Based on observation, record review, and interview the facility failed to perform hand sanitization during medication administration to 3 or 5 sampled residents (Resident 17, 28, and 18), sanitize blood glucose glucometer after use for 1 of 1 sampled resident (Resident 18), and failed to follow Enhanced Barrier Precautions (gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organism and residents at increased risk) to prevent the potential spread of multidrug-resistant infection for 2 residents (Residents 11 and 8). The facility census was 33. Findings are: A. Review of a facility supplied documents titled Employee Heath History Screen revealed the following: -Document for Housekeeper J (HSK-J) not completed in its entirety. No primary physician past medical history or allergies listed. The form is signed by HSK-J and dated 06/18/2024. There is no signature or date of the form being reviewed by other facility staff. -Document for Medication Aide K (MA-K) not completed in its entirety. No immunization record present. The form is signed by MA-K and dated 06/19/2024. There is no signature or date of the form being reviewed by other facility staff. -Document for Dietary Aide L (DA-L) completed, signed by DA-L and dated 07/30/2024. There is no signature or date of the form being reviewed by other facility staff. -Document for Maintenance Manager (MM) not completed in its entirety. No employee name listed on the form no position title emergency contact primary physician or immunization history completed. The form is signed by MM and dated 05/24/2023. There is no signature or date of the form being reviewed by other facility staff. In an interview on 08/21/2024 at 10:35 AM with the facility Business Office Manager (BOM), the BOM confirmed they are the individual responsible for ensuring all new hire documentation is completed and present in the employees file. The BOM confirmed that the Employee Health History Screen forms for HSK-J, MA-K, and MM were not completed entirely. The BOM confirmed that the forms were not reviewed to ensure that the individuals were free of communicable diseases prior to working with or in the direct vicinity of residents. B. Review of a facility policy titled Hand Hygiene and dated 2021 revealed hand hygiene is indicated and will be performed under the conditions listed in but not limited to the hand hygiene table. The Hand Hygiene Table lists hand hygiene is to be performed between resident contacts, after handling contaminated objects, before applying and after removing personal protective equipment including gloves, before preparing or handling medications. In an observation of medication administration by Registered Nurse F (RN-F), completed on 08/20/2024 from 7:20 AM to 8:20 AM the following was observed: RN-F knocked and entered Resident 17's room. RN-F gave the medications to Resident 17 in a clear plastic cup and Resident 17 then took the medications and swallowed them, and handed the clear up back to RN-F. RN-F thanked the resident and exited the room returning to the medication cart located in the hall outside of the room. RN-F threw the clear plastic cup in the trash can on the cart and placed the syringe in a clear plastic sleeve in the medication cart. RN-F then signed out the medication administration in the computer and removed the next residents' medications from the medication cart. RN-F did not complete hand sanitization/hygiene between administering Resident 17's medications and preparing the next residents' medications. Then RN-F prepared Resident 28's medications at the medication cart in the hallway located outside of Resident 28's room. RN-F knocked and entered the resident's room and handed the resident a cup containing clear liquid and a clear medication cup containing multiple medications. The resident emptied the cup containing the medications in their mouth and handed the cup back to RN-F. RN-F then returned to the medication cart in the hall signed out the medications administered in the computer. RN-F then locked the medication cart and proceeded down the hall to the nurse's station where another medication cart was located. The RN unlocked this cart and obtained a clear blue plastic pencil box from the cart. The RN did not complete hand sanitization/hygiene after administering Resident 28's medications and going to the other medication cart to get the clear blue plastic pencil box. Next RN-F entered Resident 18's room and obtained a paper towel and placed it on the resident's bed side stand. RN-F then set down a clear blue plastic pencil box on the paper towel. RN-F then applied gloves to both hands and performed the procedure of obtaining resident 18's blood sugar. After completion of the procedure RN-F removed their gloves from their hands and placed the items used back into the clear blue plastic pencil box. RN-F then picked up the box exited the resident's room and returned the box to the medication cart located at the nurse's station. RN-F did not complete hand sanitization/hygiene after removing their gloves post procedure. In an interview on 08/20/2024 at 8:25 AM completed with RN-F, RN-F confirmed hand sanitization/hygiene should have been completed after administering Resident 17 and Resident 28's medications. RN-F confirmed that hand sanitization/hygiene should have been completed after [gender] removed their gloves. C. Review of a facility policy titled Blood Glucose Monitoring dated 2021 revealed the nurse or med aide will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions. Review of a document titled Assure Platinum Reference Manual and dated 03/2014 revealed the glucometer should be cleaned and disinfected after each use. Review of a document titled General guidelines for use Super Sani-Cloth and dated 2021 revealed to allow the treated surface to remain wet for two minutes then let air dry. In an observation completed on 08/20/2024 at 7:45 AM RN-F used a glucometer to obtain Resident 18's blood sugar at the bedside. RN-F then placed the glucometer into a clear blue plastic pencil box and returned to the medication cart located down the hall by the nurse's station. RN-F placed the clear blue plastic box on the medication cart and obtained a disposable wipe from a container labeled Super Sani-Cloth located on top of the medication cart. RN-F wiped the glucometer with the disposable wipe for approximately 30 seconds. RN-F disposed of the wipe in the trash can and then placed the glucometer back into the clear blue plastic pencil box and placed it into the medication cart. In an interview on 08/20/2024 at 8:25 AM with RN-F, RN-F stated [gender] did not know the contact time or how long the surface had to remain wet for proper cleaning technique of the glucometer per the disposable wipes manufacturer recommendations. Review of the label on the container labeled Super Sani-Cloth revealed a time of 2 minutes the item being cleansed with the cloth should remain wet. RN-F confirmed this instruction was written on the label. In an interview on 08/21/2024 at 1:35 PM with the facility Director of Nursing (DNS), the DNS confirmed that the glucometer is to remain wet for 2 minutes for proper cleaning technique when using the Super Sani-Cloth disposable wipes. 41938 D. Record review of the facility policy titled Enhanced Barrier Precautions dated 4/1/24 revealed that it is the policy of the facility to implement enhanced barrier precautions for the prevention of the transmission of multidrug-resistant organisms. The definition for Enhanced Barrier Precautions (EBP) revealed that EBP is an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The policy revealed that all staff receive training on enhanced barrier precautions and are expected to comply with all designated precautions. High contact resident care activities include: Dressing, Bathing, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Wound care: any skin opening requiring a dressing. Enhanced barrier precautions should be followed outside the resident's room when performing transfers and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of an indwelling medical device. Record review of the Admission Record dated 8/19/24 for Resident 11 revealed that Resident 11 admitted into the facility on [DATE]. Record review of the Care Plan dated 8/19/24 for Resident 11 revealed that Resident 11 had a surgery for fracture of the left elbow. Resident 11 had an incision on the left arm to be observed for signs and symptoms of infection. Record review of the Treatment Administration Record (TAR, a legal record of the administration of scheduled treatments or performance of other scheduled medical tasks for a resident by a health care professional such as a licensed nurse) dated 8/20/24 for Resident 11 revealed that Resident 11 had an order for dry dressing with ace wrap changed daily. Monitor incision site for signs and symptoms of infection. Observation on 8/19/24 at 8:59 AM in the room of Resident 11 revealed that Nurse Aide-A (NA-A) transferred Resident 11 into the room in a wheelchair. Resident 11 had an ace wrap around their left elbow. A sign on the wall between the bathroom door and closet in the resident's room revealed ENHANCED BARRIER PRECAUTIONS. Everyone must clean their hands, including before entering and when leaving the room. Providers and Staff must also wear gloves and a gown for the following high contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting. Device Care or use: Central Line, Urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. A holder with gowns and gloves hung from the back of the room door. NA-A did not put on a gown or gloves. NA-A applied a gait belt (a belt device placed around a resident's abdominal area used to aid in the safe movement of a resident with mobility problems) around the abdomen of Resident 11 with the bare hands. NA-A's arms were in contact with the arms of Resident 11 as the gait belt was applied. NA-A assisted Resident 11 to stand from the wheelchair. Resident 11 held onto a walker. NA-A assisted Resident 11 to step towards the recliner as NA-A held onto the gait belt with their right hand and held onto the left arm of Resident 11 with the left hand. Resident 11 complained that NA-A was putting pressure leaning on Resident 11's left arm during the transfer. Resident 11 complained that their left arm is sore. Observation on 8/19/24 at 9:34 AM in the room of Resident 11 revealed that Physical Therapy Assistant (PTA) entered the room of Resident 11. PTA did not put on a gown or gloves. PTA put shoes on Resident 11 with the bare hands. PTA put a gait belt around the abdomen of Resident 11 and assisted Resident 11 to stand from the recliner. PTA rubbed against Resident 11 as Resident 11 stood up with the assistance. Resident 11 held onto the walker. PTA held onto the gait belt and walked with Resident 11 from the resident room to the therapy gym. Observation on 8/20/24 at 9:04 AM in the room of Resident 11 revealed that Nurse Aide-B (NA-B) did not put on a gown or gloves. Resident 11 sat in the wheelchair. NA-B placed a gait belt around the abdomen of Resident 11 with the bare hands. NA-B's bare arms rubbed against the arms and torso of Resident 11 as the gait belt was applied. NA-B held onto the gait belt and the resident's left arm pit as Resident 11 was assisted to stand. Resident 11 used the walker to transfer to the recliner. Resident 11 was assisted into the recliner as NA-B held onto the resident. Resident 11 tilted the recliner back and elevated their feet. Interview on 8/20/24 at 2:35 PM with NA-B revealed that this surveyor asked NA-B what the sign Enhanced Barrier Precautions meant. NA-B reviewed the sign and stated that it was for bathing the resident and for residents with catheters that staff have to wear gown and gloves. NA-B was unaware that gown and gloves were required for any high contact care including transfers for residents on Enhanced Barrier Precautions. Observation on 8/20/24 at 11:06 AM in the therapy gym revealed that Physical Therapist (PT) reached across the back of Resident 11 with the left hand and held onto the back of the gait belt. PT's arm was holding against the back of Resident 11. PT placed their right hand on the upper arm of Resident 11 with the right hand. PT assisted Resident 11 to sit in a chair. PT did not wear a gown or gloves. Observation on 8/20/24 at 11:09 AM in the therapy gym revealed that PTA sat down next to Resident 11. PTA told Resident 11 that the oxygen nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside your nostrils to provide supplemental oxygen therapy to people who have lower oxygen levels) needed to be adjusted. PTA grabbed the nasal cannula on the left and right of Resident 11's nose with the bare hands and adjusted the prongs into the nostrils of Resident 11. PTA tightened the cannula to hold it in place. Observation on 8/20/24 at 12:44 PM revealed that Nurse Aide-B (NA-B) transferred Resident 11 in the wheelchair from the dining room into the resident's room. NA-B did not put on a gown or gloves. NA-B pushed the wheelchair into the bathroom. NA-B put on gloves and placed a gait belt around the abdomen of Resident 11. NA-B assisted Resident 11 to stand up from the wheelchair using the gait belt. Resident 11 grabbed onto the grab bar on the wall to assist with standing. NA-B pulled down the pants of Resident 11 and then pulled down Resident 11's brief. NA-B assisted Resident 11 to sit down on the toilet. NA-B removed and discarded the gloves. NA-B asked Resident 11 to use the call light to let staff know when the resident was finished in the bathroom. NA-B exited the resident's room. Observation on 8/20/24 at 12:54 PM at the room of Resident 11 revealed that Medication Aide-C (MA-C) entered the room of Resident 11. MA-C did not perform hand sanitization. MA-C did not put on a gown or gloves. MA-C entered the resident's bathroom and asked Resident 11 if they were finished. Resident 11 responded yes. MA-C put on gloves and used a wipe to wipe the bowel movement (BM) from the resident's anal area. MA-C obtained a second wipe and wiped the resident's anal area. MA-C obtained a third wipe and wiped the resident's anal area. MA-C removed and discarded the gloves. MA-C did not perform hand sanitization. MA-C used the bare hands to assist Resident 11 to a standing position in front of the toilet. MA-C used the bare hands to pull up Resident 11's brief and pants. MA-C assisted Resident 11 to sit in the wheelchair. MA-C transferred Resident 11 out of the bathroom to near the recliner. MA-C moved the recliner as requested by Resident 11. MA-C used the bare hands to move the over bed table on the left side of the recliner towards the rear of the recliner as requested by Resident 11. MA-C positioned the wheelchair in front of the recliner. MA-C used the bare right hand to hold onto the gait belt in back of Resident 11 while draping the left arm underneath the left arm of Resident 11. MA-C held onto the front of the gait belt with the bare left hand and assisted Resident 11 to stand from the wheelchair. MA-C's uniform was touching Resident 11 as MA-C pivoted Resident 11 into the recliner. MA-C placed their bare hands on their sides touching their uniform. MA-C used the bare hands to pick up the nasal cannula from the bed and placed the nasal cannula on the face of Resident 11. MA-C used the bare hands to operate the control on the recliner to elevate Resident 11's feet and tilt the back of the chair backwards. MA-C used the bare hands to place a pillow behind Resident 11. MA-C used the bare hands to place a pillow underneath the left arm of Resident 11. MA-C entered the bathroom and performed hand washing. Resident 11 stated that the pain in their left arm was a 6 on a scale of 0-10. Resident 11 stated that they were supposed to place an ice pack to help with the pain. MA-C told Resident 11 they would get an ice pack. MA-C exited the room of Resident 11. Observation on 8/20/24 at 1:06 PM in the room of Resident 11 revealed that MA-C returned to the room with an ice pack. MA-C did not put on a gown or gloves. MA-C used the bare hands and lifted the left arm of Resident 11 and placed the ice pack under the left elbow and forearm of the resident. An ace wrap was in place on the left elbow of Resident 11. MA-C exited the resident room. Interview on 8/20/24 at 4:30 PM with Medication Aide-C (MA-C) revealed that the Enhanced Barrier Precautions means you have to gown up and wear gloves if doing anything with a resident's wounds. MA-C was not aware that gown and gloves were required for transferring and toileting residents on Enhanced Barrier Precautions. Observation on 8/21/24 at 9:57 AM in the room of Resident 11 revealed that Registered Nurse-E (RN-E) performed hand sanitization and entered the resident room after reviewing the order for the incision on Resident 11's left elbow. The incision along the bottom of the left elbow had 6 steri strips (strips of tape put across an incision for wound closure) over it. The area around the incision was a light brown along the length of the incision. The incision contained a scabbed area below the elbow measuring approximately 3 centimeters (cm) long and 1 cm wide and a scabbed area above the elbow measuring approximately 2 cm long and 1cm wide. Resident 11's left arm had a moderate amount of swelling into the fingers and was light reddish in color. Interview on 8/22/24 at 7:28 AM with the facility Director of Nursing Services (DNS) confirmed that residents on Enhanced Barrier Precautions (EBP) are to have an EBP poster sign posted to identify the resident is on EBP. The DNS confirmed that staff are expected to follow the Enhanced Barrier Precautions and wear gown and gloves for resident transfers, toileting, and wound care. The DNS revealed that the facility training to ensure staff are educated needs revised. E. Record review of the Admission Record for Resident 8 dated 8/19/24 revealed that Resident 8 admitted into the facility on [DATE]. Resident 8 had a chronic ulcer (open wound) of the left lower leg. Record review of the Care Plan dated 8/19/24 for Resident 8 revealed that staff are to observe open areas for signs and symptoms of infection. See Treatment Administration Record (TAR) for treatments. The care plan contained a care focus for Enhanced Barrier Precautions. The Care Plan revealed that Resident 8 has an open pressure wound (A localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.) and vascular wounds (wounds on your skin that develop because of problems with blood circulation) receiving treatments. Put on gown and gloves for cares at all times in the resident's room. In room care: Provide EBP care during dressing, bathing, transferring, providing hygiene care, changing bed linens, changing briefs or assisting with toileting. Observation on 8/20/24 at 2:35 PM at the room of Resident 8 revealed that a sign on the outside of the door to the room of Resident 8 read ENHANCED BARRIER PRECAUTIONS. Everyone must clean their hands, including before entering and when leaving the room. Providers and Staff must also wear gloves and a gown for the following high contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting. Device Care or use: Central Line, Urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. Interview on 8/20/24 at 2:35 PM with Nurse Aide-B (NA-B) revealed that this surveyor asked NA-B what the sign Enhanced Barrier Precautions on the door of Resident 8 meant. NA-B reviewed the sign and stated that it was for bathing the resident and for residents with catheters. NA-B stated that NA-B was unsure if it was even applicable to Resident 8 anymore. NA-B revealed that Resident 8 may have had an infection at one time. Observation on 8/21/24 at 7:37 AM in the room of Resident 8 revealed that Medication Aide-D (MA-D) and Nurse Aide-A (NA-A) were in the bathroom with Resident 8. Resident 8 was in the wheelchair. MA-D put on gloves and stood in front of the wheelchair beside the toilet. MA-D did not wear a gown. NA-A stood behind the wheelchair just inside the bathroom doorway. NA-A did not wear a gown or gloves. NA-A placed a gait belt around the lower abdomen of Resident 8. MA-D and NA-A each held onto the gait belt with one hand and supported the resident's arms with their other hand. MA-D and NA-A assisted Resident 8 to stand up from the wheelchair. MA-D removed the resident's brief. Resident 8 was assisted to sit on the toilet. Observation on 8/21/24 at 9:22 AM at the room of Resident 8 revealed that Registered Nurse -E (RN-E) reviewed the dressing change order. RN-E performed hand sanitization and put on gown, gloves, and face shield. RN-E revealed that Resident 8 had received a bath so the wound on the top of the foot was open to air. An open wound on the top of Resident 8's left foot measured approximately 8 cm long, 5 cm wide, and 0.5 cm deep. The wound bed was bright red and approximately 70% covered with a thick dark yellow-brown exudate (wound drainage). RN-E completed the wound treatment and applied the silicone foam border dressing over the wound. Observation on 8/21/24 at 10:25 AM in the room of Resident 8 revealed that Resident 8 was in bed lying on their left side. RN-E reviewed the dressing change order for the pressure ulcer on the resident's coccyx (the bony lower portion of the spine). RN-E performed hand sanitization and put on a gown, gloves, and face shield. RN-E pulled down the resident's pants and brief to just below the buttocks. An open wound was visible on the resident's coccyx. The wound measured approximately 3 cm long and 2.5 cm wide and was light red in color. An approximately 1 cm long, 0.5 cm wide, and 1 cm deep open area inside the wound near the top of the wound area was present. RN-E completed the wound treatment and applied a silicone foam dressing over the wound. Interview on 8/22/24 at 7:28 AM with the facility Director of Nursing Services (DNS) confirmed that residents on Enhanced Barrier Precautions (EBP) are to have an EBP poster sign posted to identify the resident is on EBP. The DNS confirmed that staff are expected to follow the Enhanced Barrier Precautions and wear gown and gloves for resident transfers, toileting, and wound care. The DNS revealed that the facility training to ensure staff are educated needs revised.

Licensure Reference Number 175NAC 12-006.(I) Licensure Reference Number 175NAC 12-006.(I)(i)(3) Based on observation, record review, and interviews; the facility failed to implement fall prevention interventions to prevent falls for 1 resident (Resident 25) and failed to ensure the mattress was secured to the bedframe to prevent the potential for entrapment or falls for 1 resident (Resident 25). The facility census was 33. Findings are: A. Record review of the facility policy Fall Prevention and Fall Leaf Program dated 2/2020 revealed that the purpose is to ensure fall risks are identified and interventions are implemented in an effort to prevent falls, as possible, and to maintain a safe environment for each resident of the facility. The section titled Falls revealed that if a resident incurred a fall, a Fall Incident and Investigation report is completed. The Fall Incident and Investigation report will be reviewed at the next Department Clinical Meeting for interdisciplinary review of the fall, interventions, and determination of need for additional interventions or revision of current interventions. Record review of the Admission Record dated 8/19/24 for Resident 25 revealed that Resident 25 admitted into the facility on [DATE] wiht diagnoses of: anxiety, unsteadiness on feet, muscle weakness, and history of falling. Observation on 8/19/24 at 4:13 PM in the hall between the atrium and the sunshine room revealed that Resident 28 pushed Resident 25 in a wheelchair. Resident 25 held onto a walker to the right side of the wheelchair. Resident 25 steered the walker alongside the wheelchair with their right hand. Resident 28 continued to push Resident 25 in the wheelchair through the sunshine room. Nurse Aide-A (NA-A) approached Residents 28 and 25. NA-A took the walker from Resident 25 and took the walker to the resident's room. Resident 28 continued to push Resident 25 in the wheelchair towards the resident room. Record review of the Progress Note dated 3/20/24 at 3:38 AM for Resident 25 revealed that at 3:00 AM Resident 25 called out to their spouse/roommate (Resident 28) for help. The unidentified nurse arrived at the resident room and found Resident 25 and Resident 28 on the floor. Resident 25 was bleeding from the left front of their head. Emergency Medical Technicians arrived at 3:30 AM and left Resident 25 at 4:00 AM. Record review of the Progress Note dated 8/19/24 at 8:35 PM for Resident 25 revealed that Resident 25 was found lying on the floor with their spouse/roommate (Resident 28) in the resident's room. Resident 25 could not recall why they fell . Resident 28 stated that Resident 28 tried to get Resident 25 to the toilet. During transfer, Resident 28 lost their balance, and both fell to the floor. Resident 25 complaint of a headache and soreness to the back of the head. Resident 25 got more confused and started telling staff that they were running into a wall. 911 was called. Emergency Medical Services transported Resident 25 to the emergency room at 9:15 PM. Record review of the Care Plan for Resident 25 dated 8/21/24 revealed a care focus for falls. The care plan revealed that on 3/20/24 Resident 25 called for their spouse/roommate (Resident 28) to help in the bathroom. Resident 25 fell with Resident 28 to the floor. 8/19/24 Resident 28 attempted to transfer Resident 25 to the bathroom. Resident 28 lost their balance and both Resident 28 and Resident 25 fell to the floor. Intervention for the fall on 3/20/24 revealed only that Resident 25 was sent to the emergency room and returned the same day with no acute fractures. No fall intervention to prevent future falls was developed for the 3/20/24 fall. Intervention added to the care plan on 8/19/24 for the fall on 8/19/24 revealed that staff are to place Resident 25 in a chair at meals, and staff to assist Resident 25 back to the room from meals and do cares right then so the spouse/roommate (Resident 28) is not tempted to transfer Resident 25. The intervention was dated 8/19/24. Observation on 8/21/24 at 7:33 AM in the facility dining room revealed that Resident 25 sat in a wheelchair at the dining room table. Observation on 8/21/24 at 8:07 AM in the facility dining room revealed that Resident 25 remained in the wheelchair at the dining room table feeding themselves breakfast. Observation on 8/21/24 at 8:30 AM in the facility dining room revealed that Resident 25 sat in the wheelchair at the dining room table. Observation on 8/21/24 at 8:33 AM at the nurse's station revealed that Resident 28 pushed Resident 25 in the wheelchair from the dining room through the sunshine room to the resident's room. Resident 28 pushed the wheelchair into the bathroom in the resident's room. Resident 25 stood from the wheelchair and Resident 28 backed the wheelchair out of the bathroom. An alarm was beeping at a low volume. The facility Infection Coordinator (IC) came to the room at a fast pace. IC entered the room and closed the door at 8:35 AM. Observation on 8/21/24 at 11:33 AM at the room of Resident 25 revealed that Medication Aide-H (MA-H) transferred Resident 25 from the resident's room in a wheelchair. MA-H transferred Resident 25 into the dining room and positioned Resident 25 in the wheelchair up to the dining room table. Resident 25 thanked MA-H and then asked where their spouse (Resident 28) was. MA-H told Resident 25 that they were coming. MA-H exited the dining room. Resident 28 entered the dining room at 11:34 AM and sat down in a chair at the table. Resident 28 sat to the right of Resident 25. Interview on 8/21/24 at 1:56 PM with Medication Aide-G (MA-G) confirmed that Resident 25 is at increased risk of falls. MA-G revealed that interventions to prevent falls are used to keep residents safe from falls. MA-G revealed that the charge nurse or the stand up meeting team develops new or revised fall prevention interventions after a resident has a fall. MA-G revealed that new or revised interventions are communicated to staff through the computer. MA-G revealed that when the staff log onto the computer the dashboard page displays with new messages including new fall interventions. MA-G revealed that staff usually just glance at it and move on to chart cares. MA-G revealed that staff don't have time to read it. MA-G offered to show this surveyor what the page looks like on the computer. MA-G logged onto a computer. The dashboard page was displayed. The dashboard contained no information regarding the fall of Resident 25 and contained no updated fall prevention measures. Observation on 8/21/24 at 4:50 PM in the facility dining room revealed that Resident 25 sat in a wheelchair at the table. Interview on 8/22/24 at 7:28 PM with the facility Director of Nursing Services (DNS) confirmed that new or revised interventions are expected to be developed for fall prevention after a resident has a fall. The DNS confirmed that staff are expected to follow fall interventions to try to prevent resident falls and injuries. Observation on 8/22/24 at 7:38 AM in the facility dining room revealed that Resident 25 sat at the dining room table in a wheelchair. Resident 28 was seated in a chair to the right of Resident 25. Interview on 8/22/24 at 7:55 AM with Director of Nursing Services (DNS) confirmed observation at the facility dining room that Resident 25 was seated in a wheelchair at the dining room table eating breakfast. The DNS confirmed that Resident 25 is to be placed in a regular chair at the table for the new fall prevention intervention after the resident fall on 8/19/24. The DNS confirmed that the new intervention had not been implemented. B. Record review of the facility Admission Agreement dated 10/2019 revealed that the facility must not charge a resident for room/bed maintenance services. The section titled Safe Environment revealed that the resident has a right to a safe, homelike environment. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes independence and does not pose a safety risk. Record review of the Admission Record dated 8/19/24 for Resident 25 revealed that Resident 25 admitted into the facility on [DATE] with diagnoses of: anxiety, unsteadiness on feet, altered mental status, and history of falling. Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 8/8/24 for Resident 25 revealed that Resident 25 is independent with rolling from their back to their right and their left when lying in bed. The MDS revealed that Resident 25 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 7 (a score of 0-7 indicates severe cognitive impairment). Observation on 8/18/24 at 7:40 PM in the room of Resident 25 revealed that Resident 25 was in bed. Resident 25 was lying on their back. Observation on 8/19/24 at 8:29 AM in the room of Resident 25 revealed that the mattress on the bed of Resident 25 was not secured to the bedframe. The mattress slid over approximately 14 inches from the bedframe from side to side. This created a gap for potential entrapment on the side of the bed against the wall. This created a fall hazard on the side of the bed away from the wall. Interview on 8/21/24 at 1:34 PM with facility Maintenance Manager (MM) revealed that the facility does not check to see if resident mattresses are secured to the bedframe. MM confirmed that the mattress on the bed of Resident 25 was not secured to the bedframe. MM was unaware of devices to secure mattresses to the frame. MM confirmed that MM was not aware that the mattress had to be secured to the bedframe.

Licensure Reference Number 175NAC 12-006.09 Based on observation, record review, and interviews; the facility failed to ensure the provider was notified of abnormal laboratory results affecting 1 Resident (Resident 21) of 5 sampled residents, and failed to notify a physican of blood pressures that were out of range per the physcian order for 2 Residents (Resident 24 and Resident 4) of 3 sampled residents. The facility census was 33. Findings are: A. Review of an Admission Record revealed the facility admitted Resident 21 on 12/01/2022 with diagnoses that included type two diabetes (which is when the body has trouble controlling blood sugar and using it for energy). Review of Resident 21 Physician Orders revealed an order for the facility to obtain a Hemoglobin A1C (HbA1C, a blood test that measures the average amount of glucose(sugar) in the blood over the past three months) every 3 months to be performed on the 5th of the month with a start date of 03/05/2024. Review of Resident 21's medical health record revealed a laboratory value for a HbA1C of 9.10 with a collection date of 06/07/2024. The normal reference range for this laboratory value was documented as 4.80-6.00. The result of 9.10 was indicated on the document as an abnormal value listed as High. The document provided no indication of provider review or acknowledgment of the abnormal laboratory value. Review or Resident 21's progress notes for the month of June 2024 revealed no documentation of the provider being notified of the abnormal HbA1C level or the provider reviewing the abnormal HbA1C level. In an interview completed on 08/21/2024 at 3:45 PM with the facility Medical Records (MEDR), the MEDR confirmed there was no documentation indicating the provider had been notified of the abnormal HbA1C lab value. In an interview completed on 08/21/2024 at 4:43 PM with the facility Director of Nursing (DNS), the DNS confirmed that Resident 21's HbA1C was an abnormal laboratory value, and the provider should have been notified of the abnormal value and reviewed the abnormal laboratory value indicating further directions for treatment or not to the facility. The DNS confirmed that this was not present in the resident's medical health record. 50105 B. Record review of Resident 24's Admission Record dated 08/19/2024 revealed the resident admitted on [DATE]. The admission record also reveals an admission and primary diagnosis of Parkinson's Disease (a progressive brain disorder that affects the nervous system and causes unintended or uncontrollable movements). Record review of Resident 24's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 08/18/2024 revealed the resident takes and anti-Parkinson medication. The care plan goals and interventions revealed: -The resident will be free of any discomfort or adverse side effects of anti-Parkinson therapy, -will remain free of signs and symptoms (s/s), -administer medications per physician orders, -monitor/document/report as needed (PRN) adverse reactions of anti-Parkinson therapy: increased risk of low BP on rising and falls; significant confusion, restlessness, delirium, difficulty walking/moving, nausea, dizziness, hallucinations, and agitation. Record review of Resident 24's physician orders revealed the following orders: -Carbidopa-Levodopa oral tablet 25-250 milligram (MG) give 1 tablet by mouth 3 times a day related to Parkinson's Disease: order date 02/15/2024. -Notify doctor if systolic blood pressure is greater than (>)150 or less than (<)100, heart rate >110 or <50, respiratory rate >24 or <12, oxygen saturation <90%. temperature > 100.5 Fahrenheit (F) or <95.8 F: order date 03/07/2024. Record review of Resident 24's Blood Pressure Summary report revealed the systolic blood pressure >150 or less than <100 were found on dates: -08/14/2024: 99/54 -08/05/2024: 99/54 -07/22/2024: 99/60 -04/22/2024: 89/45 Record review of Progress Notes and medical records of physician notification of blood pressure summaries or notification of systolic blood pressure >150 or less than <100 revealed no documentation that the physician was notified. C. Record review of Resident 4's Admission Record dated 08/20/2024 revealed the resident admitted on [DATE]. The admission record also reveals an admission and primary diagnosis of an injury of the cervical spinal cord, quadriplegia (a symptom of paralysis that affects a person's limbs and body from the neck down) and hypertensive heart disease (heart problems that occurred due to high blood pressure). Record review of Resident 4's Care Plan revealed the high-risk medications the resident takes are a hypertension (a condition where the pressure in your blood vessels is consistently too high) medication, and an anticoagulant (a blood thinner medication used to prevent the formation of blood clots) medication. An intervention listed for taking the medications are to notify the physician if systolic blood pressure is greater than (>)150 or less than (<)100. Record review of Resident 4's physician orders revealed the following orders: -Notify the physician if: systolic blood pressure is >150 or less than <100: order date 03/13/2024. Record review of Resident 4's Blood Pressure Summary report revealed the systolic blood pressure >150 or less than <100 found on dates: -08/20/2024: 98/54 -07/25/2024: 99/54 -07/11/2024: 94/55 -07/04/2024: 94/58 -05/30/2024: 97/70 -04/11/2024: 90/58 -03/28/2024: 96/69 -03/27/2024: 93/53 -03/26/2024: 98/68 -03/16/2024: 96/58 -03/15/2024: 88/54 -03/13/2024: 98/54 Record review of Progress Notes and medical records of physician notification of blood pressure summaries or notification of systolic blood pressure >150 or less than <100, revealed no documentation that the physician was notified. During an interview with Registered Nurse-E (RN-E) on 08/21/2024 at 4:21 PM revealed when an out-of-range vital sign is noted, and an order to notify is present, the physician's office is either called, or a fax to the physician's office is sent. Once that is completed a progress note is completed. The DNS was interviewed on 08/21/2024 at 4:40 PM confirmed there was no documentation that a physican was notified of Resident 24 and Resident 4's blood pressures out side of paramters on the listed dates. The DNS also revealed the expectation of the nurse or the charge nurse on duty is to contact the physician's office on the out-of-range vital signs. The information is then documented in the progress notes.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18 Licensure Reference Number 175NAC 12-006.18A Licensure Reference Number 175NAC 12-006.18B Based on observation, interview, and record review; the facility failed to ensure that the facility air temperatures were maintained within the regulatory temperature range of 71 F (Fahrenheit) to 81 F and comfortable levels for the residents which had the potential to affect all the facility residents. The facility failed to ensure resident areas were clean for 6 residents (Residents 8, 126, 4, 18, 16, and 6), and failed to ensure repair of sinks, toilets, or carpet for 5 residents (Residents 5, 2, 3, 15, and 6). The facility identified a census of 23 at the time of survey. Findings are: A. Observation of the facility on 6/06/22 at 6:55 AM revealed fans were running in the dining room and in the hallways. The air felt hot in the facility and the dining room. There was one yellow carpet drying fan in the hall on 400. Observation of the facility dining room on 6/6/22 at 7:14 AM revealed the dining room temperature was 86.7 F. Observation of the facility dining room on 6/6/22 at 7:17 AM revealed the thermostat on the wall in the dining room read 85 F degrees. The temperature on the 400 hall was 86.2 F. There was no ice in any of the water cups on the unit for Resident 14, Resident 3, Resident 7, Resident 5, Resident 15, and Resident 4. Interview with RN-A (Registered Nurse) on 6/6/22 at 8:10 AM revealed the facility AC (air conditioning) was not working. RN-A revealed they did not know how long the AC had not been working. RN-A revealed the staff passed ice to the residents during the night and between 2:30 PM and 3:30 PM. Observation of the facility dining room on 6/6/22 at 8:14 AM observed 15 residents were eating breakfast in the dining room. Observation of the temperature in the dining room revealed the temperature in the middle of the dining room was 86 F. 8 residents were seated in that area, Residents 12, 10, 19, 3, 21, 18, 7, and 11. The temperature by the north entrance to the dining room in proximity to the steam table was 88.5 F. Seven residents were seated in that area, Residents 14, 20, 22, 1, 13, 16, and 126. Observation of the facility dining room on 6/6/22 at 8:17 AM revealed Resident 3 was sitting in the middle of the dining room. Interview with Resident 3 at this time revealed it was too warm in the facility and the dining room. Resident 3 revealed the temperature in the facility and the dining room got worse as the day went on. Resident 3 revealed they noticed that sometimes the other residents (Resident 3 pointed to the other residents seated in the dining room) did not eat because it got so hot in the dining room. Residents 12, 18, 10, 7, 11, 3, 14, 9, 22, 1, 13, 126, 19, 21, 20, and 16 were observed sitting in the dining room. Interview with Resident 22 on 6/06/22 at 8:23 AM revealed the resident reported it's so hot in this place, the air conditioner hasn't worked since I've been here. It's terribly uncomfortable. Interview with Resident 7 on 6/6/2022 at 8:39 AM revealed sometimes it got hot in the dining room. Resident 7 was observed sitting in their wheelchair in their room at this time. No ice was observed in their water bottle. Observation of Resident 7's room on 6/06/22 at 8:44 AM revealed the window was open in their room. The room temperature was 80.6 F. There was no ice in the water cup in Resident 7's room. Interview with Resident 10 on 6/6/2022 at 8:46 AM revealed it was too warm in the dining room at breakfast. Resident 10 revealed it got even hotter at times in the dining room than it was this morning. Resident 10 revealed it had been hot in the facility for a long time. Resident 10 revealed they did not get offered extra fluids. Resident 10 was observed resting in bed in their room at this time. No ice was observed in the resident's water bottle. Observation of Resident 5 on 6/06/22 at 9:10 AM revealed Resident 5 was observed resting in bed in their room. Resident 5 was uncovered and was wearing a brief only. There was a fan running at the foot of the bed. There was no ice observed in their water bottle. Resident 5's room temperature was 84 F. Interview with Resident 5 at this time revealed it was too hot in the facility and they were uncomfortable. Resident 5 revealed yesterday and on Memorial Day it was so hot in the facility it was miserable in here. Resident 5 revealed it was ridiculous how hot it was in the facility and Resident 5 revealed they have been sweating. Resident 5 revealed they must have help to get out of bed. Resident 5 revealed the AC had never been started yet this spring. When inquired how long the AC had not been working, Resident 5 revealed the AC never had been working. Interview with Resident 3 on 6/06/22 at 9:21 AM revealed it was excessively warm in their room. Observation of Resident 4 on 6/06/22 at 9:27 AM revealed the thermostat on the wall by the door in their room read 82 F. The temperature in the middle of the room was 86 F. Resident 4 was resting in bed and had oxygen on at 2 ½ liters. There was a small fan running that was sitting on the stand next to Resident 4's bed. There was no ice in their water jug. Interview with Resident 4 at this time revealed it was too warm in their room. Resident 4 revealed they were hot and sweaty all the time and it was worse for them because they were diabetic. Resident 4 revealed the facility was not offering extra fluids. Interview with the FA (Facility Administrator) on 6/06/22 at 9:39 AM confirmed the facility air conditioner was not working and it had not worked since the spring. The FA revealed they were running fans and de-humidifiers in the facility, and they had e-mailed and talked to the facility owners and director of operations. The FA revealed no repairs had been made to the AC. Interview with Resident 8 on 6/06/22 at 11:20 AM revealed it had been hot in their room the past two months. Resident 8 revealed there was no AC (air conditioner) in their room. Resident 8 revealed they kept their door closed and used a fan. Resident 8 revealed it was difficult to breathe due to the heat. Resident 8 was observed with an oxygen concentrator and a small fan in their room. Observation of the facility dining room on 6/6/2022 at 11:42 AM revealed the dining room temperature was 86 F on the thermostat thermometer on the wall. Residents 12, 21, 18, 10, 19, 7, 11, 3, 6, 14, 20, 9, 22, 1, 13, 126, and 16 were observed sitting in the dining room. Observation of the facility on 6/6/22 at 11:45 AM revealed Residents 8, 5, 15, and 4 were observed eating their meals in their rooms. The room temperatures were warm. Interview with the FA on 6/6/22 at 1:37 PM when asked what the faciliyt was doing to help with resident comfort since the AC was not working revealed the staff were supposed to be putting ice in the resident cups to keep the water from getting lukewarm. Observation of Resident 4's room on 6/6/22 at 2:28 PM revealed the room temperature was 86 F in the middle of the room. The thermostat thermometer on the wall by the door read 84. Observation of the 400 hall on 6/6/22 at 2:32 PM revealed the temperature was 84.9 F. 1 fan was blowing in the hall along the floor. It was a carpet drying fan. Residents 21, 14, 3, 7, 5, 15, 10, and 4 had ice in their water cups. Observation of the facility on 6/6/22 at 3:35 PM revealed the ice was melted in the water cups for Residents 21, 14, 3, 7, 5, 15, and 10, and there was heavy condensation on the outside of the cups. Observation of Resident 4's room on 6/6/22 at 3:25 PM revealed the ice in Resident 4's cup was melted and there was condensation on the outside of the cup. It was warm in Resident 4's room. When inquired how the heat and humidity was making Resident 4 feel, Resident 4 reported that it was hard to breathe due to the excess heat and humidity in the facility. Resident 4 revealed they just couldn't get their breath and their chest felt real heavy all the time. Resident 4 revealed the staff told Resident 4 the resident had [CONDITION(S)]. Resident 4 stated, I have never had [CONDITION(S)]. I didn't have any trouble breathing until I came to live in this place. Resident 4 reported when they came to the facility in March it was hot and humid in the facility, and the nurses had to call the MD and get an order for oxygen for Resident 4. Resident 4 revealed they never had to use oxygen before they came to the facility. Resident 4 revealed if they didn't have the oxygen, they would not be able to breathe at all because it was so hot and humid in the facility. Resident 4 was listless and had to stop and take a breath while conversing as they would get short of breath while talking. Interview with Resident 15 on 6/06/22 at 4:18 PM revealed it was too warm in the room. Observation of the thermostat/thermometer on the wall revealed the room temperature was 86 F. The thermostat was set at 56. Interview with Resident 18 on 6/06/22 at 4:21 PM revealed it was too hot in the facility. Resident 18 revealed the heat was making it difficult to sleep at night and the heat was making Resident 18 nauseous and they did not have an appetite and found it difficult to eat. Interview with Resident 5 on 6/6/22 at 4:27 PM revealed the facility ran out of fans so they had to get someone to go downtown and buy them one with their own money as the AC was not working. The water in Resident 5's water bottle no longer had ice in it. Interview with the DON (Director of Nursing) on 6/6/22 at 4:58 PM confirmed the temperature in the dining room was stifling. The DON revealed they moved the dining area to the atrium. On 6/6/2022 at 6:03 PM The FA and DON presented their written plan to get the air temperatures down which included 2 air cooling units to be delivered tonight and more to follow and they will assess all the residents. Observation of Resident 4's room on 6/07/22 at 10:00 AM revealed Resident 4 was sitting on the edge of their bed in their room. A small fan on the stand next to Resident 4's bed was running. The room curtain was open, and the sun was shining in Resident 4's room. It was hot in Resident 4's room. There was a jug of water and a jug of yellow drink that looked like lemonade or Mountain Dew soda both half full with no ice in them. The temperature in the middle of the room was 89.6 F. Interview with Resident 4 at this time revealed they liked it warm in their room but that it was a little too warm. Resident 4 revealed no one came and talked to them about getting a different fan. Resident 4 thought a bigger fan would help. Resident 4 revealed someone came in an turned the wall AC unit on, but it didn't work and there was no air coming out of it. Interview with the FA on 6/07/22 at 10:15 AM revealed the temperature in Resident 4's room was 84 F this morning and Resident 4 told them they liked it warm in their room. When the FA was notified it was 89.6 F in Resident 4's room the FA revealed they would offer Resident 4 a larger fan. Observation of Resident 5's room on 6/07/22 at 10:28 AM revealed they were resting in bed in their room wearing a brief only. Interview with Resident 5 at this time revealed it was still warm in their room, but the fan was helping. Observed a pedestal fan that was blowing on Resident 5. There was no ice in Resident 5's water bottle. Interview with the DON on 6/07/22 at 10:35 AM revealed Resident 4 was comfortable with 84 degrees. When notified the temperature in Resident 4's room was now 89.6 F, the DON revealed they would offer Resident 4 a bigger fan or offer to move Resident 4 to a cooler room due to the sun shining on Resident 4's window causing the temperature in Resident 4's room to go up. Observation of the FA at this time revealed they took a pedestal fan into Resident 4's room. Interview with the DON 6/07/22 at 1:15 PM revealed they were still working with Resident 4 on a plan for their room temperature. Interview with the DON on 6/07/22 at 3:40 PM revealed Resident 4's room temperature was 84 now and it was 86 this AM when the DON checked it. The DON revealed they tried putting a dehumidifier in Resident 4's room and it would not stay on. The DON revealed they would get a portable air conditioner at the store, but Resident 4 reported to the DON they really did not want their window boarded up which is what they would have to do to pipe the exhaust out from a portable AC unit. The DON revealed they could get a different type of unit online, but it would not be here until Friday. The DON revealed Resident 4 preferred the unit they would have to order, however, the DON revealed they were still not getting the temperature in Resident 4's room down below 81 and the DON revealed Resident 4 told them they were okay with that. Interview with Resident 4 on 6/07/22 at 3:50 PM revealed they did not want their window altered. Resident 4 revealed they did not want to make that much work for the facility and if it were them, they would not board the window up. Resident 4 revealed they could take quite a bit of heat. When it was discussed with Resident 4 about the temperature being over 89 degrees this AM in their room, Resident 4 revealed the sun did shine on their room due to the location of their room. Resident 4 revealed that now they had a pedestal fan, and the air circulating had helped a lot and that was the biggest thing for them. Resident 4 did agree to have staff turn the fan up and close their window curtain to keep the sun out and Resident 4 revealed they would report any concerns with breathing or sweating to the facility immediately. Interview with the DON on 6/07/22 at 4:03 PM revealed they would order the cold ice evaporator and continue to monitor Resident 4 and increase the air in the room, close the curtain, and offer fresh icy drinks. The DON revealed they would also look at tinting the windows, getting Resident 4 a neck fan, and offering cold packs. Observation of Resident 4 on 6/08/22 at 7:30 AM revealed Resident 4 was observed sitting up on the edge of their bed in their room. The room temperature was 78 F. Both fans were running. Interview with Resident 4 at this time revealed they were comfortable at this time, and they had slept better last night. Resident 4 also revealed they were breathing better. Observation of Resident 4's room on 6/08/22 at 2:25 PM revealed the air temperature in their room was 78 F from thermometer on the wall. Interview with Resident 4 at this time revealed they were comfortable with the room temperature. Observation of Resident 4's room on 6/09/22 at 8:32 AM revealed the room temperature was 80 F from wall thermometer. 2 fans were running, and the window curtains were closed. Resident 4 had a water jug in reach and yellow colored drink in another mug. Interview with Resident 4 at this time revealed they were comfortable. Resident 4 had no signs of respiratory distress. Oxygen was on at 2 ½ LPM. Review of the Accuweather air temperatures for the community for March, April, May, and June 2022 revealed the temperatures over 70 F were listed for the following dates: March 1- 75°, March 2-76°, March 20-78°, April 9-75°, April 12-89°, April 20-70°, April 21-72°, April 22- 92°, April 23-74°, April 26-76°, April 27-77°, April 28-82°, May 7-79°, May 8-79°, May 9-79°, May 10-78°, May 11-90°, May 12-89°, May 13-79°, May 14-74°, May 15-72°, May 16-82°, May 17-79°, May 18-84°, May 19-90°, May 26-77°, May 27-90°, May 28-89°, May 29-80°, May 30-75°, May 31-71°, June 2-77°, June 3-81°, June 4-84°, June 5-72°, June 6-80°, June 7-75°, June 8-76°, June 9-77°. Observation on 6/7/2022 at 7:15AM revealed the Facility had 2 portable cooling units piped out through the ceiling in the halls-one on 400 and one on 300. The facility obtained 2 more units that were set up in the halls on 300 and 400 mid-morning. The units ran in the halls. None of the rooms had AC units in them. B. Observation on 6/6/22 at 8:05 AM in the facility dining room revealed that the room temperature felt hot. An oscillating fan was running by the fire extinguisher. A floor fan was running by the east dining room entry door. Facility residents were in the dining room for the breakfast meal. Interview on 6/6/22 at 9:39 AM with the Facility Administrator (FA) confirmed that the facility air conditioning (AC) cooling unit had been broken for awhile. The FA added that the cooling unit had been broken since the beginning of spring and that the FA had told the facility owners. The FA confirmed that the facility indoor air temperature was over the upper limit of the required safe temperature range. The FA revealed that the facility has been running fans and dehumidifiers to keep residents comfortable. The FA revealed that the FA had emailed and talked to the company Director of Operations for an estimate for repairs on the whole cooling unit. The FA revealed that a heating and air company was at the facility and said that the job was too large for their crew. The FA revealed that the heating and air company had a crew at another office that would be able to help. The FA revealed that the heating and air company was to provide an estimate to the facility this week on the repairs to the cooling unit. The FA revealed that facility interventions for residents due to no air conditioning included room fans for residents. The FA revealed that the facility Atrium has its own separate cooling unit and that the Atrium room is cooler. The FA revealed the facility had placed fans in the hallways and had been monitoring air temperatures in the facility daily. The FA revealed that the facility had a lot of grievances (complaints) on the hot temperature in the facility. The FA revealed that to assist with resident comfort the facility was getting residents out of their rooms especially for meals. Interview on 6/6/22 at 1:37 PM with the Facility Administrator (FA) revealed that the FA provided a copy of emails sent to the corporate office on 5/18/22 and 5/24/22. The FA revealed that the facility was waiting on an estimate for the repair of the cooling unit. The FA revealed that the heating and air company that was to be providing the estimate was to send the estimate directly to the FA. The FA revealed that the facility was making sure that the residents received ice water and that the facility was making sure that the water was not getting lukewarm. Record review of the email from the FA to the corporate office dated 5/18/22 at 12:55 PM revealed that the subject was documented as: AC unit update. The FA wrote that the FA had called the heating and air company to come and look at the AC situation and give the facility an estimate. Record review of the email from the FA to the corporate office dated 5/24/22 at 3:09 PM revealed that the subject was documented as: RE: AC unit update. The FA wrote that the Maintenance Director (MD) had called the heating and air company to give the facility an estimate for the current AC situation. The email revealed that the heating and air company visited the facility on 5/23/22 to assess the AC situation. The email revealed that the facility was currently trying to find mechanical plans for the building. The email revealed that the heating and air company was going to send the facility an estimate for the air handler that currently needs to be replaced. The email revealed that when the air handler is turned on it currently sounds like a freight train coming through the building so it needs some parts and repairs done to it. Interview on 6/6/22 at 3:22 PM with Registered Nurse-A (RN-A) revealed that the facility is checking resident temperatures one time per shift (every 12-hour shift). RN-A confirmed that the facility nursing staff is not checking the air temperatures in resident rooms or in the facility. Interview on 6/6/22 at 3:23 PM with the FA revealed that the FA did not find any documentation of air temperature monitoring in the facility in 2022. Observation on 6/6/22 at 3:34 PM in the room of Resident 8 revealed that the resident sat in the chair in the corner of the resident's room. Resident 8 had a nasal cannula in place to receive oxygen at 3 liters per minute from the oxygen concentrator. Resident 8 breathed with pursed lip breathing (a breathing technique designed to make your breaths more effective by making them slower and more intentional when you are having difficulty breathing). Resident 8 revealed that the resident was having trouble breathing and had pressure on the chest and back due to there being no cool air to breathe. Resident 8 confirmed that the high temperature in the building was causing difficulty with the resident's breathing. Interview on 6/6/22 at 3:37 PM with the Director of Nursing (DON) confirmed that the required air temperature in the facility was to be between 71-81 degrees Fahrenheit. Interview on 6/6/22 at 4:21 PM with Resident 18 revealed that it was too hot in the facility. Resident 18 revealed that the resident can't sleep due to it being hot in the facility. Resident 18 revealed that the heat makes Resident 18 nauseous in the dining room and made it difficult for Resident 18 to eat. Observation in 6/6/22 at 6:03 PM in the facility room being used by the survey team revealed that the DON provided the survey team with a copy of the updated plan to correct the temperature in the facility. Record review of the facility document titled Plan to correct Temperature in the facility on 6/6/22 at 6:03 PM revealed that it included: 1. Assessed all resident's immediately upon notification of temperature discrepancies. 2. Obtained temperature of all rooms to identify out of temperature areas. 3. The facility will check the temperature in all rooms mid-morning and late afternoon daily. 4. The facility will move any residents in a room out of temperature range to a room that is within temperature range. 5. The facility moved the resident dining from the facility dining room to the atrium for all meals. 6. The facility will assess residents for heat concerns especially the ones with [CONDITION(S)] or any other respiratory illness every day and evening shift. 7. The facility will get 2 portable air conditioner units by 9:00 PM on 6/6/22 for cooling and 1 more unit on 6/7/22. 8. The facility will continue the system purchase process. 9. Educate staff on heat exposure signs and symptoms and appropriate room temperature ranges. 10. If portable air coolers are in an egress area, the facility will notify the Fire Marshal. The Immediate Jeopardy was abated at this time and the scope and severity was lowered to 'F'. Observation on 6/7/22 at 7:30 AM in the 300 hall revealed a portable cooling unit in place blowing cool air into the hallway. Observation on 6/7/22 at 8:10 AM at the nurse's station revealed that the ADON provided education to Medication Aide-D (MA-D) and RN-A on the signs and symptoms of heat injury. The ADON reviewed the facility form for documenting twice daily monitoring of each resident to include the air temperature in the resident's room. The ADON provided education on how to use the thermometer to determine the air temperature in the resident rooms. Observation on 6/7/22 at 10:19 AM revealed that the temperature per the portable thermometer was 78.8 degrees outside of the room of Resident 18. Interview on 6/7/22 at 10:47 AM with the FA revealed that the FA provided a grievance log sheet for June 2022. The FA revealed that the facility didn't have a Social Services Director for a while. The FA revealed that the Business Office Manager (BOM) took over facility grievances and that the June 2022 grievance log sheet is what the BOM had. Record review of the June 2022 Grievance/Complaint Log revealed that the facility received 3 grievances. A grievance dated 5/28/22 from Resident 18 revealed that Resident 18 was concerned with the temperature in the dining room and bedroom. A grievance dated 5/28/22 from Resident 21 revealed that Resident 21 was too uncomfortable in the dining room to eat and could not get comfortable. A grievance dated 5/28/22 from Resident 4 revealed that Resident 4 did not understand how the resident's room is so hot. The comments, actions, and follow up section on the Grievance/Complaint Log for each of the 3 grievances documented that the BOM spoke to the administrator about the grievance and that the administrator was already working on getting bids from different companies to repair the AC unit. Observation on 6/8/22 at 7:08 AM outside of the room of Resident 2 revealed an air temperature of 72.8 degrees per portable thermometer. Observation on 6/8/22 at 7:09 AM outside of the room of Resident 8 revealed an air temperature of 74.2 degrees per portable thermometer. Observation on 6/8/22 at 7:08 AM outside of the room of Resident 18 revealed an air temperature of 71.9 degrees per portable thermometer. Interview on 6/8/22 at 7:33 AM with Resident 18 revealed that the facility temperature was much more comfortable and that you don't have to pull at your shirt because it is so hot. Observation on 6/8/22 at 7:45 AM revealed that Resident 8 sat in the chair in the corner of the room with legs crossed on the chair. A blanket was in place covering the resident's legs and lap. Resident breathed with no pursed lip breathing or other signs of respiratory distress. Resident 8 revealed that the resident was enjoying the cooler air. Observation on 6/9/22 at 8:27 AM outside of room 308 revealed an air temperature of 75.9 degrees. Observation on 6/9/22 at 8:27 AM outside of room 311 revealed that the FA and ADON exited the room. At 8:29 AM the air temperature in the room was 79.3 degrees. Interview on 6/9/22 at 8:30 AM with Licensed Practical Nurse-C (LPN-C) revealed that Resident 8 was moved to a different room during the night. LPN-C confirmed that Resident 8's room was too hot, so the resident was moved to another room temporarily. Observation on 6/9/22 at 8:31 AM in the temporary room of Resident 8 revealed that the FA and ADON set up an oscillating stand fan in the room. Interview on 6/9/22 at 8:32 AM with Resident 8 revealed that the resident got hot in the middle of the night and had trouble breathing. Resident 8 revealed that the staff moved the resident to this different room. The temperature in the room with Resident 8 revealed a temperature of 79.1 degrees per portable thermometer. C. Record review of the facility Admission Agreement dated 10/2019 revealed that the resident has a right to a safe, clean, comfortable homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on 6/6/22 at 9:20 AM in the room of Resident 8 revealed that the bathroom exhaust fan vent cover was covered with fuzzy gray/white debris. Observation on 6/6/22 at 9:26 AM in the room of Resident 126 revealed that the bathroom exhaust fan vent cover was covered with fuzzy grayish debris and a curly black hair hung from the vent cover. Observation on 6/6/22 at 9:27 AM in the room of Resident 4 revealed that the bathroom exhaust fan vent cover was covered with gray debris. Observation on 6/6/22 at 9:28 AM in the room of Resident 18 revealed that the toilet base was soiled with brownish black debris between the toilet base and the floor. Observation on 6/6/22 at 9:30 AM in the room of Resident 16 revealed that the bathroom exhaust fan vent cover was covered with fuzzy white/gray debris. Spider webs were present running from the fire sprinkler pipes near the bathroom ceiling to the light fixture above the sink in the bathroom. The toilet bowl contained dried brown/black stool splotches inside of the bowl and on the stool riser. The base of the toilet was soiled with brownish black debris between the toilet base and the floor. Observation on 6/6/22 at 9:34 AM in the room of Resident 6 revealed that the bathroom exhaust fan vent cover was covered with fuzzy gray debris and had spider webs hanging from it. Observation on 6/9/22 at 1:02 PM in the room of Resident 8 with the Facility Administrator (FA) confirmed that the bathroom exhaust fan vent cover was covered with fuzzy gray/white debris. Observation on 6/9/22 at 1:07 PM in the room of Resident 126 with the FA confirmed that the bathroom exhaust fan vent cover was covered with fuzzy grayish debris and a hair hung from the vent cover. Observation on 6/9/22 at 12:52 PM outside the room of Resident 4 with the FA revealed that Resident 4 did not provide permission to enter the resident's room to confirm that the bathroom exhaust fan vent cover was covered with gray debris. Observation on 6/9/22 at 12:55 PM in the room of Resident 18 with the FA confirmed that the toilet base was soiled with brownish black debris between the toilet base and the floor. Observation on 6/9/22 at 12:59 PM in the room of Resident 16 with the FA confirmed that the bathroom exhaust fan vent cover was covered with fuzzy white/gray debris. The FA confirmed that spider webs were present running from the fire sprinkler pipes near the bathroom ceiling to the light fixture above the sink in the bathroom. Observation on 6/9/22 at 12:57 PM in the room of Resident 6 with the FA confirmed that the bathroom exhaust fan vent cover was covered with fuzzy gray debris and had spider webs hanging from it. D. Record review of the facility Admission Agreement dated 10/2019 revealed that the resident has a right to a safe, clean, comfortable homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on 6/6/22 at 7:17 AM at the door to the room of Resident 5 revealed that the carpet over the threshold was loose. The surveyor caught their foot on the carpet. Observation on 6/6/22 at 9:14 AM in the room of Resident 2 revealed that the toilet handle was broken and the toilet would not flush. Interview on 6/6/22 at 9:18 AM with Resident 2 revealed that the toilet in the resident's room had been broken for at least a week. Observation on 6/6/22 at 9:21 AM in the room of Resident 3 revealed that the bathroom sink did not drain. Observation on 6/6/22 at 9:24 AM in the room of Resident 15 revealed that the light above the sink in the resident's bathroom flickered constantly and was bright. The bathroom sink did not drain. The lower wall of the bathroom contained gouges. Drywall was torn away by the closet in the resident's room next to the hand sanitizer dispenser. Observation on 6/6/22 at 9:34 AM in the room of Resident 6 revealed that the vinyl floor outside of the bathroom was wet and slick. Water leaked from around the base of the toilet and there were standing water puddles on the bathroom floor. The bathroom floor contained orange-yellow stains surrounding the standing water puddle edges. Observation on 6/9/22 at 1:05 PM with the Facility Administrator (FA) in the room of Resident 2 revealed that the toilet handle had been repaired. Interview on 6/9/22 with Resident 2 revealed that the Maintenance Director (MD) had repaired the toilet handle so that the toilet could be flushed. Observation on 6/9/22 at 12:53 PM in the room of Resident 3 with the FA confirmed that the bathroom sink did not drain. Observation on 6/9/22 at 12:49 PM in the room of Resident 15 with the FA confirmed that the light above the sink in the resident's bathroom flickered. The FA confirmed that the bathroom sink did not drain. The FA confirmed that the lower wall of the bathroom contained gouges. The FA confirmed that drywall was torn away by the closet in the resident's room next to the hand sanitizer dispenser. Observation on 6/9/22 at 12:57 PM in the room of Resident 6 with the FA confirmed that water le [TRUNCATED]

Licensure Reference Number 175 NAC 12-006.09D2b Based on observation, interview, and record review; the facility staff failed to implement interventions to promote the healing of pressure ulcers for 4 of 4 sampled residents including completing assessments, using clean technique for dressing changes, repositioning, and administering nutritional supplements as ordered. This affected Residents 3, 29, 24 and 34. The facility identified a census of 34 at the time of survey. Findings are: A. Review of Resident 3's quarterly MDS (minimum data set-a comprehensive assessment tool used to develop a resident's care plan) dated 3/7/2018 revealed an admission date of [DATE]. Resident 3 had a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer that was not present at the time of admission. Review of Resident 3's admission MDS dated [DATE] revealed Resident 3 was admitted to the facility on [DATE] and had one Stage 2 pressure ulcer that was not present upon admission/entry or reentry. The date of the oldest Stage 2 pressure ulcer was 8/4/2016. Review of Resident 3's Physician Order Report for 2/6/2018-3/6/2018 revealed a [DEVICE] was being used to treat a sacral (tailbone) wound. Observation of Resident 3 on 3/14/18 at 7:31 AM, 9:28 AM, 1:36 PM, 3:17 PM and 4:20 PM revealed Resident 3 was sitting in the wheelchair. Interview with Resident 3 on 3/14/2018 at 3:17 PM revealed Resident 3 had been up in the chair since 7:30 AM and had not laid down in bed. Review of Resident 3's Resident Progress Notes for 3/14/2018 revealed no documentation Resident 3 had been offered the opportunity to change positions or educated about the risks of refusing to change positions. Observation of Resident 3 on 3/15/18 at 7:09 AM, 10:52 AM, 1:05 PM, 1:49 PM, and 3:20 PM revealed Resident 3 was sitting in the wheelchair. Review of Resident 3's Resident Progress Notes for 3/15/2018 revealed no documentation Resident 3 had been offered the opportunity to change positions or educated about the risks of refusing to change positions. Review of the undated NA (Nurse Aide) Pocket Guide revealed the following instructions for Resident 3: Lay down BID (twice) during the day. Interview with NA-U on 3/19/18 at 1:48 PM revealed the direct care staff carried pocket care plans with care instructions for the residents. Residents with pressure ulcers or who were at risk for skin breakdown were to be repositioned every 2 hours. Review of Resident 3's Medications Flow sheet for January, February, and (MONTH) (YEAR) revealed documentation that Resident 3 had wound area (pressure ulcer) pain and wound vac change pain ranging in intensity of 10/10 (worst pain you can imagine) 8 out of 10 and severe to very severe pain due to the pressure ulcer. Review of Resident 3's Wound Clinic note dated 2/16/18 revealed Resident 3's coccygeal (tailbone) ulcer went deep into the subcutaneous fat and the dressing changes were causing more discomfort. Review of Resident 3's Physician Order Sheet dated 3/7/2018 revealed the following: wound care nurse wrote a note to provider: routine wound vac changes are becoming extremely painful when wound is cleansed. Observation of RN-C (Registered Nurse) on 3/19/2018 at 11:22 AM doing dressing change for Resident 3's pressure ulcer to coccyx/sacrum (tailbone area) being treated with a [DEVICE] revealed the following: RN-C did 1 second hand scrub with hand sanitizer and applied gloves. The hand sanitizer did not cover all surfaces of RN-C's hands and RN-C's hands did not appear wet. RN-C then closed Resident 3's room curtains touching the rod with the gloved hands. RN-C then lowered the head of the bed touching the bed control with the same gloved hands. RN-C then picked the trash can up by the rim and moved it to where RN-C was working. RN-C then got more gloves out of the box in the bathroom and put them in the dressing bin. RN-C did not change gloves after touching the trash can before touching the gloves they put in with the other dressing supplies. RN-C then got supplies including [MEDICATION NAME] (pain medication) and dressings, touching them with the same gloved hands. RN-C then touched the bed control to raise the bed. RN-C then took the reservoir out of the [DEVICE] pump and removed the tubing. RN-C then removed the soiled dressings from Resident 3's pressure with the same gloves touching the wound. Resident 3 hollered out twice while RN-C was pulling the old dressing off. RN-C then rummaged around the bin of supplies with the soiled gloves and retrieved more supplies. RN-C then touched the wound edge and the dressing sponge that was in the wound with the same gloves. RN-C then discarded the sponge, put new gloves on, and squirted the [MEDICATION NAME] in the wound without performing hand hygiene. RN-C then put the new canister in the [DEVICE] pump that they had already touched with the dirty gloves. RN-C then opened the clean dressing package and touched the sponge. RN-C then took a pair of scissors out of their pocket and cut the sponge. RN-C did not clean the scissors or change gloves. RN-C then cut the transparent dressings with the scissors that were in their pocket. RN-C then washed the wound with soap and water on a washcloth and used a plain wet washcloth to rinse. RN-C then sprayed Resident 3's wound with wound cleanser and rinsed with saline, touching the canister of wound cleanser before placing it back in the bin with the remainder of the dressing supplies. The pressure ulcer to Resident 3' tailbone was deep. RN-C then changed gloves without performing hand hygiene. RN-C then got a dressing out of the tub that they had been rummaging in. RN-C then cut the sponge with the scissors they had taken out of their pocket and used without cleaning and placed it in the wound. RN-C then placed the cut transparent dressings around and over the wound and the sponge. RN-C then attached the hose to the canister after applying the adhesive dressings. RN-C then changed gloves without performing hand hygiene. RN-C then tore a hole in the dressing that was in the wound with a gloved finger. RN-C then turned the [DEVICE] pump on that was sitting on the floor. Resident 3 flinched twice after RN-C turned the [DEVICE] pump on and the suction started. RN-C then put the scissors in their pocket without cleaning them. Review of Resident 3's Wound Evaluation flow sheet dated 2/28/2018 revealed documentation that Resident 3's pressure had potential signs of infection including green slime exudate (drainage). Review of the facility policy hand hygiene revised 3/18 revealed the following: Purpose: to prevent the spread of infection through adherence of good hygiene practices. Policy: all personnel shall wash their hands with soap and water or use hand sanitizer to prevent the spread of infections. Wash hands with antimicrobial soap and water when hands are visibly soiled. Use an alcohol-base waterless antiseptic for routinely decontaminating hands when hands are not visibly soiled . When to practice hand hygiene: between resident contacts; after removing gloves; anytime hands are soiled; when going from a dirty to clean function on the same resident. Hand hygiene methods: antiseptic hand rub: apply adequate amount of alcohol-based waterless solution to palm of one hands. Rub hands together, covering all surfaces of hands and fingers, until hands are dry. Antiseptic hand wash: Moisten hands with water then apply enough soap to produce a lather. Rub hands vigorously for at least 10-15 seconds. Review of Resident 3's Wound Evaluation Flow Sheet received 3/14/2018 revealed no documentation Resident 3's pressure ulcer had been assessment since 3/5/2018. Interview with LPN-G (Licensed Practical Nurse) on 3/19/18 at 1:07 PM confirmed there was no documentation Resident 3's pressure ulcer had been assessed since 3/5/2018 (9 days). Review of Resident 3's progress notes for 3/5/2018-3/15/2018 revealed no documentation of an assessment of Resident 3's pressure ulcer. Interview with the DON (Director of Nursing) on 3/19/18 at 01:08 PM it was their expectation that wounds were assessed and documented on weekly. Review of Resident 3's Physician's Orders revealed the following: Peanut butter and jelly sandwich once a day at 3:00 PM with an order date of 10/26/2017, Ensure (dietary supplement) at each meal with an order date of 10/11/2017, and ProStat (protein supplement) 1 ounce twice a day mixed in diet soda with an order date of 3/16/2018. Review of Resident 3's Resident Supplement Chart for 2/17/18 to 3/18/18 revealed incomplete documentation of the supplement intake: PB & J (Peanut Butter and Jelly) sandwich only charted 3 days out of the month. Breakfast supplement (Ensure) was not charted on 2/17, 2/25, 3/9, 3/10, 3/11, and 3/15. Lunch supplement (Ensure) was not charted 2/17, 2/18, 2/24, 2/25, 3/4, 3/9, 3/10, 3/11, 3/15, 3/17, 3/18. Dinner supplement (Ensure) not charted on 2/19, 2/22, 2/24, 3/1, 3/2, 3/7, 3/10,3/11, 3/16, 3/17, and 3/18. Interview with the RD-O (Registered Dietitian) on 3/19/18 at 2:59 PM confirmed Resident 3 had a pressure ulcer that was not healing. RD-O confirmed the dietary supplements were not documented and should have been. RD-O revealed Resident 3 had been receiving Ensure TID (three times a day) and it was changed on 3/16/2018 to ProStat BID that is charted on the MAR (Medication Administration Record). Review of Resident 3's MAR for (MONTH) (YEAR) revealed the ProStat was started on 3/16/2018. The ProStat was documented as administered on 3/18 AM and 1700 (5 PM). It was not documented as administered any other time. B. Interview with Resident 29 on 3/13/18 at 3:22 PM revealed they were being treated for [REDACTED]. Resident 29 revealed they were supposed to go to the hospital last week and get the pressure ulcer surgically closed but it got infected so that got put on hold. Review of Resident 29's admission MDS dated [DATE] revealed an unhealed Stage 3 (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) pressure ulcer 2.0 cm long; 2.0 cm wide and 2.2 cm deep. Review of Resident 29's annual MDS dated [DATE] revealed an unhealed Stage 3 pressure ulcer that was 2.7 cm log, 2.2 cm wide and 3.2 cm deep which indicated the pressure ulcer had gotten larger. Interview with LPN-G on 3/19/18 at 1:34 PM revealed Resident 29 had a Stage 4 pressure ulcer that was marked a Stage 3 pressure ulcer on the annual MDS dated [DATE]. LPN-G confirmed the MDS should have reflected Resident 29 had a Stage 4 pressure ulcer. Review of Resident 29's Wound Evaluation Flow Sheet dated 8/29/17 revealed the pressure ulcer to the left ischium (hip/buttock) measured 1.4 cm x 1.4 cm x 1.8 cm. The pressure ulcer was a Stage 3 at that time. Review of Resident 29's Wound Evaluation Flow Sheet dated 12/5/2017 revealed the pressure ulcer to the left ischium measured 2 cm x 2 cm x 2 cm. Review of Resident 29's Wound Evaluation Flow Sheet dated 2/12/2018 revealed Resident 29 had a Stage 4 pressure ulcer to the left ischium (hip/buttock) that measured 2.7 cm (centimeters) by 2.2 cm and was 3.2 cm deep. The documentation on the Wound Evaluation Flow Sheet indicated the pressure ulcer had gotten larger and deeper. Observation of pressure ulcer care for Resident 29 on 3/13/2018 at 11:33 AM revealed the following: MA-B moved Resident 29's personal belongings from the over the bed table. RN-C then placed the supplies for the dressing change on the table which included scissors, dressings, and tubing. RN-C did not clean the table or apply a barrier before putting the dressing supplies on the table. RN-C donned gloves then turned off the [DEVICE] pump that was sitting on the floor. RN-C clamped the tubing from the [DEVICE] pump to the dressing on Resident 29's left hip then removed the soiled dressing. RN-C then removed the gloves, applied hand sanitizer and rubbed hands for 2 seconds then donned another pair of gloves. RN-C then washed the wound with a washcloth they had retrieved from the bathroom. The pressure ulcer was deep to the left hip. RN-C then opened the dressing package and cut the foam and clear adhesive dressings with the scissors that had been lying on the table. RN-C then laid the cut dressings onto the outside of the dressing package and the table. RN-C then placed one of the cut foam dressings into the pressure ulcer. RN-C then applied another piece of foam dressing that had been lying on the table onto the wound. RN-C then applied the clear adhesive dressings over the foam dressings then used the scissors that had been lying on the table to cut a hole into the clear adhesive dressings. RN-C then removed the gloves, washed hands for 3 seconds then applied another pair of gloves. RN-C then used a pre-moistened wipe to wash Resident 29's back side. RN-C applied a clean brief then assisted with repositioning Resident 29 to their back by touching the turn sheet then proceeded to wipe Resident 29's front side of the perineum (bottom). RN-C did not change gloves after cleaning Resident 29's back side before touching the clean brief, turning sheet, and cleaning Resident 29's front side. RN-C then removed the gloves, donned another pair of gloves then finished dressing Resident 29's bottom. RN-C then removed the gloves then touched the bed rail and gave Resident 29 the call light cord, which Resident 29 then proceeded to touch. RN-C then picked the scissors up off the table that they had used during the dressing change and put them in their pocket. RN-C did not wipe the table off or the scissors and did not perform hand hygiene after removing gloves. Review of Resident 29's Progress Notes for 12/15/2017 to 3/15/2018 revealed Resident 29 was treated for [REDACTED]. Review of Resident 29's Wound Culture Reports dated 2/27/18, 1/9/18, 12/27/17, and 12/22/17 revealed the pressure ulcer to Resident 29's left ischium showed infection. Interview with LPN-G on 3/15/18 at 11:14 AM confirmed that Resident 29's pressure ulcer to the left ischium was infected. Review of Resident 29's [DIAGNOSES REDACTED]. Review of Resident 29's Wound Evaluation Flow sheet revealed documentation the last assessment of Resident 3's pressure ulcer was 2/27/2018. The pressure ulcer was 1.8 cm long, 3.5 cm wide and 3 cm deep. Interview with LPN-G on 3/19/18 at 1:07 PM confirmed there was no documentation Resident 29's pressure ulcer had been assessed since 2/27/2018 (14 days). Review of Resident 29's Resident Progress Notes revealed no documentation of an assessment of Resident 29's pressure ulcer. Interview with the DON (Director of Nursing) on 3/19/18 at 01:08 PM it was their expectation that wounds were assessed and documented weekly. Review of Resident 29's Physician Order Report for 1/26/2018-2/26/2018 revealed an order for [REDACTED]. Review of Resident 29's Resident Supplement Chart documentation for 2/17/2018 to 3/18/2018 for cottage cheese per RD-O revealed there was incomplete documentation on 2/17, 3/6, 3/8, 3/11, 3/12, 3/13, and 3/15. Interview with the DON on 3/19/18 at 04:08 PM revealed that standard protocol was that hands were cleaned after gloves were used. After touching a dirty area with the hands or gloved hands staff were expected to clean hands and put on clean gloves. The DON confirmed the dressing changes were to be done as a clean procedure; by clean you would go from dirty to clean. Staff were expected to use a clean surface, wash the scissors, get their stuff together first and then put their gloves on and not touch everything. Review of the facility policy Pressure Ulcer Care revised 11/29/07 revealed the following: Residents having pressure ulcers receive necessary treatment and serves to promote healing, prevent infection, and prevent new pressure ulcers from developing. The resident's plan of care will be reviewed and revised at least quarterly and more often if a decline in function is apparent. Width and depth for Stage 3 and Stage 4 will be measured weekly. The physician will be notified of any pressure ulcers and a wound consult will be ordered. The physician will be notified weekly of the healing status of the pressure ulcer. Standard precautions will be utilized during wound care. C. Interview on 3-13-18 at 11:08 AM with Resident 24 revealed the resident had skin sores on the right calf and right heel and all had a dressing on them. Record review of the Pressure Ulcer Weekly Physician Notification form for Resident 24 revealed a unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) pressure ulcer to the right heel was identified 05/11/17. The initial measurement was documented as 1 cm (centimeter) x 0.8 cm x no depth. Review of the Wound Evaluation Flow Sheet dated 2-15-18 revealed the right heel pressure ulcer had increased in size and measured at 2 cm x 1.8 cm x 0.3 cm with dark eschar with severe pain documented. No further measurements were found of the pressure ulcer on the right heel. Observation of LPN-G on 3-15-18 at 1:30 PM revealed LPN-G performed the dressing changes to Resident 24's pressure ulcer wounds to the right calf and right heel. When LPN-G went to perform the dressing to the right heel, LPN-G revealed the Theraskin was not on the right heel and should have been. Interview on 3-19-18 at 10:01 AM with the LPN-G (Licensed Practical Nurse), who was also the wound nurse) revealed the resident had seen a Physician for the wounds on 2-22-18 and the initial Theraskin (a skin graft treatment to help heal wounds) had been applied to the pressure wounds. LPN-G revealed once the Theraskin had been applied, the dressing was only to be removed one time a week. On (MONTH) 1, LPN-G revealed LPN-G assessed the wound but did not document an assessment of the wounds. On (MONTH) 8 Resident 24 went to the Physician's office and LPN-G confirmed there were no papers received from the Physician's clinic to reveal the assessment of the wound. On (MONTH) 15, LPN-G performed the dressing changed and there was no assessment documented. The only documentation was in the PN (Progress Notes) which Area to R (right) heel appears to not have Thera Skin on. Clarification sent to Physician. Record review of Resident 24's current Careplan revealed the resident was to be in the recliner after breakfast and in bed after lunch for interventions to address the pressure ulcers. Record review of the Turn Schedule dated 3-15-18 to 3-16-18 which was hung on the resident's closet door revealed the resident was not turned for 3 hours from 0600 till 0900 on 3-15-18. Interview on 3-15-18 at 09:12 AM with NA-E (Nurse Aide) revealed the resident was extensive assist with cares. Resident 24 can tell the staff what the resident needs were. NA-E revealed the resident was turned every 2 hours during the night and after breakfast and lunch was laid down. Observation on 3-13-18 at 11:08 AM revealed the Resident sitting in the wheelchair. Observation on 3-14-18 at 09:30 AM revealed Resident 24 sitting in the wheelchair at an activity. Observation on 3-14-18 at 11:30 AM revealed Resident 24 sitting in the resident's room in the wheelchair. Observation on 3-14-18 at 1:37 PM revealed Resident 24 sitting in the resident's room in the wheelchair. Observation on 3-14-18 at 3:10 PM revealed Resident 24 sitting in the wheelchair in the resident's room. Observation on 3-14-18 at 4:07 PM revealed Resident 24 sitting in the wheelchair in the resident's room. Observation on 3-15-18 at 9:10 AM revealed Resident 24 was assisted out of bed by the staff for breakfast. Observation on 3-15-18 at 11:41 AM revealed Resident 24 was sitting in the wheelchair in the resident's room Observation on 3-19-18 at 11:17 AM revealed Resident 24 sitting in the wheelchair with the resident's head slumped forward asleep. Observation on 3-19-18 at 11:54 AM revealed Resident 24 sitting in the wheelchair. Observation on 3-19-18 at 2:30 PM revealed the resident was lying down in bed on the left side. However both of the residents legs, where the pressure ulcers were, were lying flat on the mattress and no offloading of pressure was to the wounds. Interview on 3-15-18 at 1:25 PM with Resident 24 revealed the resident lays down when the staff ask the resident but they had not been asking the resident. D. Review of Progress Notes in Matrix dated 2/22/18 upon admission revealed no measurements or staging of pressure ulcers. Review of Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning purposes) dated 2/28/18 for Resident 34 revealed a BIMS (brief interview for mental status, test how you are functioning cognitively at the moment) score of 5, this indicated severe cognitive impairment. Review of undated [DIAGNOSES REDACTED]. that can cause urination difficulty), Suprapubic indwelling catheter (a surgically created connection between the urinary bladder and the skin around the umbilical region used to drain urine from the bladder), osteo[DIAGNOSES REDACTED] (bone infection), kidney disease, decubitus (pressure) ulcers (resulting from prolonged pressure on the skin), bursitis of the right hip (hip pain), [MEDICAL CONDITION] (decreased blood flow to extremities). Interview on 03/15/18 at 02:50 PM with Resident # 34 revealed, when asked, Do you lay down during the day? Resident 34 replied, Sometimes. They haven't been by to ask me to lay down yet. Interview on 03/15/18 at 03:08 PM with MA-D (Medication Aide-D) revealed staff assist the resident by helping put pants on. Resident 34 was able to do own shirt and other small tasks such as brushing teeth and combing hair. When asked about transfers MA-D stated, Resident can stand and walk pretty good. Doesn't usually lay down after meals and gets one bath a week per resident's request. MA -D confirmed resident has a sore on the the left heel and left hip. During an observation on 03/19/18 at 02:34 PM of dressing change to Resident 34's pressure ulcer on left heel and behind left ankle, RN-C did not remove soiled gloves prior to touching clean items in a plastic bag. Continued observation of the dressing change revealed RN-C placed the plastic bag of items on the floor with no barrier between the floor and the plastic bag. Bloody drainage ran onto items placed on a wash cloth on the floor for the dressing change. RN-C sat on the bare floor to complete the dressing change. RN-C did not change gloves from beginning of dressing change to the end. RN-C did not wash hand or use hand sanitizer. RN-C contaminated a pair of scissors taken from uniform pocket and replaced them into the same pocket without cleaning them. Observation on 03/19/18 at 02:34 PM during a complete dressing change on Resident 34 to left heel and back of left ankle by RN-C. RN-C washed hands. RN-C then pulled a trash can over to the side of Resident 34's wheelchair. Placed a white cloth on the floor by the wheelchair. Placed soapy clothes on the white cloth on the floor. RN-C placed a plastic bag which contained numerous items of dressings, bandages, tape, ointments, and Saline Spray on Resident 34's bed. Saline spray is used to moisten dressings to make them easier to remove when they become stuck. It is clean (sterile) since it is in a closed container. RN-C then put on gloves. RN-C sat down, on the floor, in front of Resident 34's wheelchair. The white cloth is on the floor just to her right. RN-C began to remove Resident 34's sock and shoe from the left foot. RN-C began to remove the old dressing, which was soaked with bloody drainage, from Resident 34's foot and back of ankle. RN-C then reached into the pocket of RN-C's uniform and removed a pair of scissors. The scissors were placed on the white cloth with the other clean items for the dressing change. The bloody dressing became stuck, closer to the skin. RN-C reached into the plastic bag which contained numerous supplies for dressing changes. RN-C dug into the bag several time and was unable to locate what item was needed. RN-C then slid the bag of supplies to the uncovered floor, not on the white cloth, and removed the can of Saline Spray. RN-C sprayed the soiled dressing, which began to run down and drip onto the scissors and other items on the white cloth on the floor. RN-C tried to remove the dressing and Resident 34 stated Ouch! That hurts! RN-C informed Resident 34 that the dressing was stuck. RN-C sprayed the dressing again and it came off. RN-C then took two (2) 4 X 4 gauze pads, touched the tube of [MEDICATION NAME] gel and squeezed the ointment onto the two (2) 4 X 4 gauze pads. RN-C did not change gloves, wash hands or use hand sanitizer. RN-C then placed the one (1) 4 X 4 gauze pad onto the wound on the back of the left ankle. RN-C then needed to apply skin prep (a protective coating that helps guard the skin against irritations) to the ulcer on the left heel. Resident 34 asked if it was going to burn. Resident 34 was hard of hearing and could not hear RN-C. Resident 34 replied, What did you say? RN-C stated, Hold on and applied the skin prep. Resident 34 stated, That hurts! RN-C then applied one (1) 4 X 4 gauze pad on the left heel, making no reply to Resident 34's comment about pain. RN-C reached into the plastic bag of supplies, took out a roll of Kerlix wrap and secured the 4 X 4 dressings into place. RN-C then used tape to hold the Kerlix wrap into place. The tape and [MEDICATION NAME] were placed back into the plastic bag. RN-C then placed the scissors back into uniform pocket. Resident 34 replied several time, My foot still hurts! RN-C informed Resident 34 that it was because the dressing was stuck. RN-C informed Resident 34 that the dressing and cleaning of the suprapubic catheter site would be done next. (Suprapubic catheter is a surgically created connection between the bladder and the skin used to drain urine from the bladder when a person has an obstruction (blockage) of normal urine flow). RN-C took off the gloves from the previous dressing change. No washing of hands or use of hand sanitizer was observed. RN-C gathered the supplies needed with ungloved hands. RN-C with ungloved hand moved trash can closer to the resident's wheelchair. RN-C then applied gloves, without washing them or using hand sanitizer. RN-C prepared the wash clothes to clean the catheter site. RN-C removed the old dressing and placed it into the trash can. New gloves were applied and the area around the site was cleaned. Area cleaned with soap and water, moving from inward at insertion site outward. Gloves were not changed, new dressing was applied and secured with tape. Tape placed back into plastic bag of supplies. Resident 34's clothing was adjusted and trash picked up from room. RN-C replied, I will wash my hands later. RN-C went into bath house and use hand sanitizer. Review of Treatments Flow Sheet dated 3/1/18-3/31/18 revealed dressing changes had been done 3/15/18, 3/18/18 and 3/19/18 with no measurements recorded on the, WOUND EVALUATION FLOW SHEET. Resident 34 had order for Profo Boot-offloading pressure on 3/6/18. Boots did not start getting applied until 3/16/18. Care Plan does not reveal what procedure was being done prior to Profo Boots. Review of Progress Notes dated 2/22/18 through 3/19/18 revealed no documentation since admission of resident refusing to be assisted to bed. Observation for five (5) hours from 09:15 AM until 01:50 PM revealed resident sitting in the wheelchair in various locations around the facility. Review of undated Care Plan revealed Resident 34 has no interventions that include changing positions and documenting refusals to lay down.